The National Center on
Addiction and Substance Abuse
at Columbia University
^COLUMBIA
633 Third Avenue
New York, NY 10017^706
phone 212 841 5200
fax 212 956 8020
www.casacolumbia.org
Hoard qf Directors
Jeffrey B. Lane
Chairman
Joseph A. CaJifano, Jr.
Founder and Chair Emeritus
William H. Foster, Ph.D.
President and CEO
Lee C. Bollinger
Ursula VI. Hums
Columba Bush
Kenneth I. Chenault
Peter R. Dolan
Victor F. Gan/.i
Melioda B. Hilriebrand
Ralph Izzo, Ph.D.
Gene F. Jankowski
David A. Kessler, M.D.
Jeffrey B. Kindler
.Alan I. Leshner, Ph.D.
Rev. Edward A. Malloy, CSC
Doug Morris
Bruce F,. Mosler
Manuel T. Pacheco, Ph.D.
Joseph J. Plumeri
Jim Bamstad
Shari E. Redstone
F. John Rosenwald, Jr.
Michael I. Roth
Mara Burros Sandler
Michael P. Schulhof
Louis W. Sullivan, M.D.
John J. Sweeney
Clyde C. Higgle
Directors Emeritus
James E. Burke (1992-1997)
Jamie Lcc Curtis (2001-2009)
Jamie Dhnon (1995-2009)
Mary Fislier (1996 2005)
Betty Ford (1992-1998)
Douglas A. Fraser (1992-2003)
Barbara C. Jordan (1992-1996)
Leo Kehnenson (1998 2006)
Donald R. Keough (1992 2010)
LaSalle Lefiall (1992-2001)
Nancy Reagan (1995-2000)
Linda J. Rice (1992-1996)
George Bupp (1993-2002)
Michael I. Sovern (1992-1993)
Frank G. Wells (1992-1994)
Michael A. Wiener (1997-2009)
Addiction Medicine:
Closing the Gap between Science and Practice
June 2012
Funded by:
The Annenberg Foundation
The Diana, Princess of Wales Memorial Fund and The Franklin
The New York Community Trust
Adrian and Jessie Archbold Charitable Trust
Board of Directors
Lee C. Bollinger Rev. Edward A. Malloy, CSC
President, Columbia University President Emeritus, University of Notre Dame
Ursula M. Burns Doug Morris
Chairman and CEO, Xerox Corporation CEO, Sony Music Entertainment
Columba Bush
Former First Lady of Florida
Joseph A. Califano, Jr.
Founder and Chairman Emeritus, CAS A Columbia
Kenneth I. Chenault
Chairman and CEO,
American Express Company
Peter R. Dolan
Chairman, ChildObesityl80
William H. Foster, Ph.D.
President and CEO, CASA Columbia
Victor F. Ganzi
Chairman of the Board PGA Tour
Melinda B. Hildebrand
Ralph Izzo, Ph.D.
Chairman of the Board, CEO and President,
Public Service Enterprise Group, Inc. (PSEG)
Gene F. Jankowski
President, CBS Broadcasting, Retired
David A. Kessler, M.D.
Jeffrey B. Kindler
Jeffrey B. Lane
Chairman, CASA Columbia
Alan I. Leshner, Ph.D.
CEO, Executive Publisher, Science, American
Association for the Advancement of Science
Directors Emeritus
James E. Burke (1992-1997)
Jamie Lee Curtis (2001-2009)
Jamie Dimon (1995-2009)
Mary Fisher (1996-2005)
Betty Ford (1992-1998)
Douglas A. Fraser (1992-2003)
Barbara C. Jordan (1992-1996)
Leo- Arthur Kelmenson (1998-2006)
Bruce E. Mosler
Chairman, Global Brokerage,
Cushman & Wakefield, Inc.
Manuel T. Pacheco, Ph.D.
President Emeritus, University of Arizona and
University of Missouri System
Joseph J. Plumeri
Chairman and CEO,
Willis Group Holdings PLC
Jim Ramstad
Former Member of Congress (MN-3)
Shari E. Redstone
President, National Amusements, Inc.
E. John Rosenwald, Jr.
Vice Chairman Emeritus, J.P.Morgan
Michael I. Roth
Chairman and CEO, The Interpublic Group
of Companies, Inc.
Mara Burros Sandler
Michael P. Schulhof
Chairman, GTI Holdings LLC
Louis W. Sullivan, M.D.
President Emeritus, Morehouse School of Medicine
John J. Sweeney
Clyde C. Tuggle
Senior Vice President, Chief Public Affairs and
Communications Officer, The Coca-Cola Company
Donald R. Keough (1992-2010)
LaSalle D. Leffall, Jr., M.D., F.A.C.S. (1992-2001)
Nancy Reagan (1995-2000)
Linda Johnson Rice (1992-1996)
George Rupp, Ph.D. (1993-2002)
Michael I. Sovern (1992-1993)
Frank G. Wells (1992-1994)
Michael A. Wiener (1997-2009)
Copyright ©2012. All rights reserved. May not be used or reproduced without the express written permission of The National Center
on Addiction and Substance Abuse at Columbia University.
The CASA Columbia National Advisory Commission on Addiction Treatment
Drew E. Altman, PhD (Chair)
President and Chief Executive Officer
The Henry J. Kaiser Family Foundation
Harvey V. Fineberg, MD, PhD
President
Institute of Medicine
Mark S. Gold, MD
University of Florida College of Medicine
and McKnight Brain Institute
Departments of Psychiatry, Neuroscience,
Anesthesiology, Community Health & Family
Medicine
Chairman, Department of Psychiatry
Shelly F. Greenfield, MD, MPH
Chief Academic Officer, McLean Hospital
Professor of Psychiatry,
Harvard Medical School
Director, Clinical and Health Services Research
and Education
Division on Alcohol and Drug Abuse,
McLean Hospital
Elizabeth R. Kabler
President
Rosenstiel Foundation
Myles V. Lynk, JD
Peter Kiewit Foundation
Professor of Law and the Legal Profession
Faculty Fellow, Center for Law, Science &
Innovation's Program in Public Health Law
and Policy
Sandra Day O'Connor College of Law
Arizona State University
June E. Osborn, MD
President Emerita
Josiah Macy, Jr. Foundation
Manuel T. Pacheco, PhD
President Emeritus, University of Arizona
and University of Missouri System
The Honorable Jose R. Rodriguez
Circuit Judge
Ninth Judicial Circuit of Florida
Reverend Msgr. Stephen J. Rossetti, PhD, DM in
Clinical Associate Professor
Associate Dean for Seminary
and Ministerial Programs
The Catholic University of America,
The School of Theology and Religious Studies
Former President and Chief Executive Officer
Saint Luke Institute, Inc.
Leonard D. Schaeffer
Judge Robert Maclay Widney
Chair & Professor
University of Southern California
Steven A. Schroeder, MD
Distinguished Professor of Health and Health
Care, Department of Medicine
Director, Smoking Cessation Leadership Center
University of California, San Francisco
Louis W. Sullivan, MD
President Emeritus
Morehouse School of Medicine
Table of Contents
Foreword and Accompanying Statement by Drew Altman, PhD i
I. Introduction and Executive Summary 1
The CASA Columbia Study 4
Key Findings 6
Addiction Is a Brain Disease 6
As with Other Health Conditions, There Are Clear Risk Factors for
the Development of Addiction 7
Addiction Frequently Co-Occurs with Other Health Conditions 7
Addiction Can Be a Chronic Disease 7
A Lack of Standardized Terminology Compromises Effective Interventions 7
Multiple Addictive Substances and Behaviors Frequently Are Involved in
Risky Use and Addiction 7
Public Attitudes about the Causes of Addiction Are Out of Sync with the Science 8
Physicians and Other Health Care Providers Should Be on the Front Line for
Addressing this Disease 8
Screening and Intervention Are Effective at Addressing
Risky Substance Use and Forestalling Addiction 9
Effective Therapies to Treat and Manage Addiction Exist 9
The Importance of Tailored Interventions and Treatment 10
Public Attitudes about Addiction Treatment Reflect the Prevailing
Non-Medical Approach to Addiction Care 10
Most People in Need of Treatment Do Not Receive It 10
Most Referrals to Publicly Funded Treatment Come from the
Criminal Justice System 1 1
Less than Half of Treatment Admissions Result in Treatment Completion 12
Patients Face Formidable Barriers to Receiving Addiction Treatment 12
The Spending Gap 12
Most Funding for Addiction Treatment Comes from Public Sources 13
The Education, Training and Accountability Gap 13
The Profound Disconnect between Evidence and Practice 13
Recommendations and Next Steps 14
Reform Health Care Practice 14
Use the Leverage of Public Policy to Speed Reform in Health Care Practice 15
II. What Is Addiction? 19
Addiction Is a Brain Disease 20
The Risk Factors for Addiction 22
Genetic Risks 22
Biological Risks 23
Psychological Risks 23
Environmental Risks 23
Early Initiation of Use 24
Risky Use and Addiction Frequently Co-Occur with Other Health Conditions 24
Addiction Can Be a Chronic Disease 25
Models for Understanding Addiction 26
Evolving Approaches to Addressing Addiction 26
Defining the Terms 29
The Continuum of Substance Use 29
Public Attitudes about Addiction 34
Perceived Causes of Addiction 35
III. Prevalence and Consequences 39
Defining the Problem 40
Risky Substance Users 41
Risky Tobacco Use 43
Risky Alcohol Use 44
Risky Illicit Drug Use 46
Risky Use of Controlled Prescription Drugs 47
Addiction 48
Special Populations 5 1
Pregnant Women 5 1
Adolescents and Young Adults 51
Older Adults 52
Co-Occurring Disorders 52
Members of the Military Exposed to Combat 53
Involvement in the Justice System 55
Consequences of Risky Substance Use and Untreated Addiction 55
Tobacco 58
Alcohol 59
Illicit Drugs 60
Controlled Prescription Drugs 61
IV. Screening and Early Intervention 63
The Need for Patient Education, Screening and Intervention throughout the Lifespan ....64
Childhood and Adolescence 64
Young Adulthood 65
Middle and Later Adulthood 65
Attending to Co-Occurring Conditions 66
Patient Education and Motivation 66
Screening 66
Laboratory Tests 68
Brief Interventions and Treatment Referrals 69
Tobacco 69
Alcohol and Other Drugs 70
Effectiveness of Screening and Brief Interventions 71
Tobacco 72
Alcohol 72
Other Drugs 73
Implementing Screening and Brief Interventions in Health Care and Other Settings 74
Primary Care 74
Emergency and Trauma Care 76
Health Care for Pregnant Women 77
Mental Health Care 78
Dental Care 78
Pharmacies 78
High School, College and University Settings 78
Justice Settings 79
The Workplace 80
Government-Funded Social Service Systems 81
Barriers to Effective Implementation of Screening and Brief Interventions 81
Insufficient Training 81
Competing Priorities/Insufficient Resources 82
Inadequate Screening Tools 83
V. Treatment and Management of Addiction 85
A Comprehensive Approach to Treatment 86
Assessment 87
Stabilization 88
Cessation of Use 88
Detoxification 89
Acute Care 92
Pharmaceutical Therapies 92
Psychosocial Therapies 102
Combined Therapies 104
Nutrition and Exercise 106
Chronic Disease Management 107
Medically Supervised Disease Management 107
Case Management 108
Support Services 109
Mutual Support Services 109
Auxiliary Support Services 113
The Use of Technology in Addiction Treatment and Disease Management 1 14
Public Attitudes about Addictive Substances and the Need for Addiction Treatment.... 1 14
Perceptions of the Relative Need for Treatment Based on Substance of Addiction .1 14
Perceptions of the Goals of Treatment 115
Perceptions of the Types of Interventions that Constitute Treatment 116
Perceptions of the Effectiveness of Treatment 116
VI. Tailored Treatment for Special Populations 119
Co-occurring Medical Disorders 119
Co-occurring Mental Health Disorders 120
Tobacco Cessation 121
Treatment for Addiction Involving Alcohol and Other Drugs 121
Adolescents 122
Tobacco Cessation 122
Treatment for Addiction Involving Alcohol and Other Drugs 123
Women 124
Pregnant Women 124
Older Adults 125
Racial and Ethnic Minorities 126
Individuals of Minority Sexual Orientation 126
Veterans and Active Duty Military 127
Individuals Involved in the Justice System 128
Juvenile Offenders 128
Adult Corrections 128
VII. The Addiction Treatment Gap 131
Most People in Need of Treatment Do Not Receive It 133
Variations in the Treatment Gap by Primary Substance Involved 134
Variations in the Treatment Gap by Key Patient Characteristics 135
Regional Variations in the Treatment Gap 137
Sources of Funding for Addiction Treatment 137
Privately-Funded Treatment 138
Publically-Funded Treatment 138
Trends in Spending on Addiction Treatment 139
Expenditures by Providers and Types of Services 139
Treatment Admissions 141
Treatment Referrals and Venues 142
Treatment Completion 145
Variations in Treatment Completion by Source of Referral 146
Variations in Treatment Completion by Primary Substance Involved 146
Variations in Treatment Completion by Key Patient Characteristics 146
Link between Funding Source, Type of Service Provided and Treatment Completion ..146
Barriers Patients Face in Accessing and Completing Addiction Treatment 147
Misunderstanding of the Disease 147
Negative Public Attitudes and Behaviors Toward People with Addiction 148
Privacy Concerns 150
Cost 151
Lack of Information about How To Get Help 152
Limited Availability of Services 152
Insufficient Social Support 153
Conflicting Time Commitments 153
Negative Perceptions of the Treatment Process 153
Legal Barriers 154
Barriers to Treatment Access and Completion in Special Populations 154
Individuals with Co-Occurring Conditions 154
Pregnant and Parenting Women 155
Adolescents 155
Older Adults 156
The Homeless 156
Veterans and Active Duty Military 157
Rural Populations 157
Native Americans 158
VIII. The Spending Gap 159
The Rational Approach to Risky Substance Use and Addiction 159
Costs of Our Failure to Prevent and Treat Addiction as a Medical Condition 160
The Largest Share of Costs Falls to the Health Care System 160
Cost Savings of Addiction Screening, Intervention and Treatment 161
Screening and Early Intervention 162
Addiction Treatment and Disease Management 164
Insurance Coverage of Addiction Treatment is Limited 166
Parity Laws 166
The Patient Protection and Affordable Care Act of 2010 168
Gaps in Coverage within Public and Private Insurance Plans Continue to
Impede Comprehensive Addiction Care 169
IX. The Education, Training and Accountability Gap 175
The Size and Shape of the Addiction Treatment Workforce 176
Licensing and Credentialing Requirements for Individuals who Provide
Addiction Treatment 177
Medical Professionals 178
Mental Health Professionals 183
Acupuncturists 185
Addiction Counselors 186
Licensure, Certification and Accreditation Requirements for Addiction Treatment
Programs and Facilities 187
State Licensing Requirements 188
Federal Regulatory Requirements 189
Accreditation Requirements 190
Professional Staffing Requirements 191
Treatment Service Requirements 193
Quality Assurance Requirements 195
X. The Evidence-Practice Gap 199
Current Approaches to Risky Substance Use and Addiction Are Inconsistent
with the Science and Evidence-Based Care 199
Patient Education, Screening, Brief Interventions and Treatment Referrals 200
Assessment, Stabilization and Acute Treatment 204
Tailored Treatment Services 208
Chronic Disease Management 210
Barriers to Closing the Evidence-Practice Gap 212
The Addiction Treatment Workforce is Not Qualified to Implement
Evidence-Based Practices 212
Health Professionals do not Implement Evidence-Based Addiction Care Practices .216
Inadequate Use and Development of Pharmaceutical Treatments for Addiction 219
Inadequate Quality Assurance 220
Inadequate Insurance Coverage 222
No Overarching Organizing Body for Addiction Science and Treatment 223
Efforts to Integrate Substance Use Prevention and Treatment into
Mainstream Medicine 223
XL Recommendations and Next Steps 227
Reform Health Care Practice 228
Incorporate Screening and Intervention for Risky Substance Use,
and Diagnosis, Treatment and Disease Management for Addiction
into Routine Medical Practice 228
All Medical Schools and Residency Training Programs Should Educate and
Train Physicians to Address Risky Substance Use and Addiction 229
Require Non-Physician Health Professionals to Be Educated and Trained to
Address Risky Substance Use and Addiction 229
Develop Improved Screening and Assessment Instruments 230
Establish National Accreditation Standards for All Addiction Treatment
Facilities and Programs that Reflect Evidence-Based Care 230
Standardize Language Used to Describe the Full Spectrum of Substance Use and
Addiction 230
Use the Leverage of Public Policy to Speed Reform in Health Care Practice 231
Condition Grants and Contracts for Addiction Services on the Provision of
Quality Care 231
Educate Non-Health Professionals about Risky Substance Use and Addiction 23 1
Identify Patients at Risk in Government Programs and Services where Costs of
Risky Use and Addiction Are High 23 1
Develop Tools to Improve Service Quality 23 1
License Addiction Treatment Facilities as Health Care Providers 232
Require Adherence to National Accreditation Standards that
Reflect Evidence-Based Care 232
Require that All Insurers Provide Coverage for Comprehensive Addiction Care 232
Expand the Addiction Medicine Workforce 232
Implement a National Public Health Campaign 233
Invest in Research and Data Collection to Improve and Track Progress in Addiction
Prevention, Treatment and Disease Management 233
Implement the National Institutes of Health's (NIH) Recommendation to Create a
Single Institute Addressing Substance Use and Addiction 234
Appendix A-Methodology 235
Appendix B-Key Informant Interview Guide and List of Key Informants 245
Appendix C-National Addiction Belief and Attitude Survey (NABAS) 253
Appendix D-Survey of New York State Addiction Treatment Directors 269
Appendix E-Survey of New York State Addiction Treatment Staff 285
Appendix F- National Panel and National Online Survey of Members of Professional
Associations Involved in Addiction Care 297
Appendix G-Survey of Participants in Recovery 305
Appendix H- Screening and Assessment Instruments 311
Notes 325
Bibliography 429
Accompanying Statement by
Drew E. Altaian, PhD, Chair, The CASA Columbia
National Advisory Commission on Addiction Treatment
In homes, doctors' offices, hospitals, schools,
prisons, jails and communities across America,
misperceptions about addiction are undermining
medical care. Although advances in
neuroscience, brain imaging and behavioral
research clearly show that addiction is a
complex brain disease, today the disease of
addiction is still often misunderstood as a moral
failing, a lack of willpower, a subject of shame
and disgust. Addiction affects 16 percent of
Americans ages 12 and older— 40 million people.
That is more than the number of people with
heart disease (27 million), diabetes (26 million)
or cancer (19 million). Another 32 percent of
the population (80 million) uses tobacco, alcohol
and other drugs in risky ways that threaten
health and safety.
Like other public health and medical problems,
we understand the risk factors for addiction. We
have effective ways of screening for risky use
and intervening. While as of now there is no
cure for addiction, there are effective
psychosocial and pharmaceutical treatments and
methods of managing the disease. But as this
landmark report by CASA Columbia shows in
sharp detail, this is where the comparison with
other health conditions ends. Unlike other
diseases, we do little to effectively prevent and
reduce risky use and the vast majority of people
in need of addiction treatment do not receive
anything that approximates evidence-based care.
The medical system, which is dedicated to
alleviating suffering and treating disease, largely
has been disengaged from these serious health
care problems. The consequences of this
inattention are profound. America's failure to
prevent risky use and effectively treat addiction
results in an enormous array of health and social
problems such as accidents, homicides and
suicides, child neglect and abuse, family
dysfunction and unplanned pregnancies. CASA
Columbia estimates that risky substance use and
-i-
addiction are this nation's largest preventable
and most costly health problems, accounting for
one third of hospital inpatient costs, driving
crime and lost productivity and resulting in total
costs to government alone of at least $468
billion each year.
In many ways, America's approach to addiction
treatment today is similar to the state of
medicine in the early 1900s. In 1908, the
Council on Medical Education of the American
Medical Association turned to the Carnegie
Foundation for the Advancement of Teaching to
conduct a survey of Medical Education in the
U.S. That survey, which became known as the
Flexner Report, was led by Abraham Flexner
who famously observed of the discrepancy
among physicians' qualifications, "there is
probably no other country in the world in which
there is so great a distance and so fatal a
difference between the best, the average and the
worst." This CASA Columbia report identifies a
similar gulf in the knowledge and practice skills
of addiction treatment providers today. The
education and training of persons providing
addiction treatment vary considerably by state.
In many cases, entry requirements for the
profession are minimal in terms of education and
are based on apprenticeship models rather than
on science-based instruction.
Flexner noted that the turn of the 19th to 20th
century was a time of scientific progress in the
understanding of disease and its treatment;
however, due to the lack of a standardized and
rigorous education for physicians, society reaped
"but a small fraction of the advantage which
current knowledge has the power to confer."
Similarly, 1 00 years later, advances in science
and medicine have drawn a much clearer picture
of addiction-including its causes, correlates and
how to treat it— yet we are woefully unprepared
to apply this evidence to practice. Our medical
professionals are not trained to look for risky use
and addiction or to intervene or treat the disease.
Without medical attention, the disease
progresses, forcing doctors to expend valuable
resources treating the more than 70 other
conditions requiring medical attention that result
from substance use and addiction, while
taxpayers shoulder the costs of these health and
other social consequences. This neglect by the
medical system has led to the creation of a
separate and unrelated system of addiction care
that struggles to treat the disease without the
resources or the knowledge base to keep pace
with science and medicine.
Because addiction affects cognition and is
associated primarily with the difficult social
consequences that result from our failure to
prevent and treat it, those who suffer from the
disease are poor advocates for their own health.
And due in large part to the shame, stigma and
discrimination attached to the disease,
individuals with addiction and their family
members too often are isolated in their struggle
to understand the disease and find help. Only
recently have we begun to see those affected by
the disease working to raise awareness in ways,
for example, that families of breast cancer
victims have done. But these efforts are small,
challenged by public misunderstanding and have
failed to raise sufficient funding for needed
research.
Even individuals who can transcend the stigma
face significant barriers to receiving effective
care, and this report paints a dismal picture of a
treatment 'non-system. ' While almost half of
Americans say they would go to their health care
providers for help, most doctors are uninformed
about this disease and rarely are equipped to
offer a diagnosis, provide treatment or connect
patients with appropriate specialty care.
Insurance coverage varies widely. Services
rarely are tailored to individual needs and are
based primarily on an acute care model rather
than recognizing the chronic nature of the
disease. There are no national standards of care.
Patients face a patchwork of treatment programs
with vastly different approaches; many offer
unproven therapies and little medical
supervision. Some promise "one time" fixes;
others offer posh residential treatment at
astronomical prices with little evidence
justifying the cost. Even for those who do have
insurance coverage or can pay out-of-pocket,
there are no outcome data reflecting the quality
of treatment providers so that patients can make
informed decisions.
-n-
This report focuses long overdue attention on the
disease of addiction. It clarifies the important
difference between this disease and risky use of
addictive substances; identifies the human and
economic costs of our current approach to these
health problems; and documents the breadth of
available knowledge on how to prevent risky use
and treat addiction.
As our nation struggles to reduce skyrocketing
health care costs, there are few targets for cost
savings that are as straightforward as preventing
and treating risky substance use and addiction.
This report shows that modest public health
interventions and relatively inexpensive
addiction therapies, compared with other
medical treatments, would reduce this burden
significantly.
The report calls for modernizing addiction
treatment-to harness the scientific knowledge
we have acquired to prevent risky use and treat
this disease. This report is a call to action. Like
the Flexner Report a century ago, it shines a
bright light on the problem and offers a roadmap
for action. Addiction Medicine: Closing the Gap
between Science and Practice represents more
than five years of intensive research, and draws
on policy and treatment research conducted by
CASA Columbia over two decades and on a
wide body of scientific, clinical and policy
research conducted by others. This major
undertaking was the result of the work of a large
team of dedicated individuals and institutions
and was conducted with the able advice and
counsel of The CASA Columbia National
Advisory Commission on Addiction Treatment
which 1 had the privilege to chair. The
Commission includes an impressive group of
individuals knowledgeable about the many
aspects of substance use and addiction in
America today. We are grateful for their expert
assistance.
The project was made possible by the generous
financial support of The Annenberg Foundation;
The Diana, Princess of Wales Memorial Fund
and The Franklin Mint; The New York
Community Trust; and the Adrian and Jessie
Archbold Charitable Trust.
Peter D. Hart Research Associates conducted the
National Addiction Belief and Attitude Survey
for this report; Survey Research Laboratory
(SRL) of the University of Illinois at Chicago
administered the survey of New York State
addiction treatment providers. We are grateful
to Karen Carpenter-Palumbo, former director of
the New York State Office of Alcoholism and
Substance Abuse Services (OASAS) for helping
to make the New York State survey possible.
We thank the following organizations which
generously helped connect CASA Columbia
with treatment providers who participated in a
national online survey of members of
professional associations involved in addiction
care: The American Academy of Addiction
Psychiatry (AAAP); the American Association
for the Treatment of Opioid Dependence
(AATOD); the American Psychological
Association (APA); the American Society of
Addiction Medicine (ASAM); the Association
for the Treatment of Tobacco Use and
Dependence (ATTUD); NAADAC, the
Association for Addiction Professionals; the
National Association of Addiction Treatment
Providers (NAATP); the National Association of
County Behavioral Health and Developmental
Disability Directors (NACBHDD); the National
Council for Community Behavioral Healthcare
(National Council); the State Associations of
Addiction Services (SAAS); and Treatment
Communities of America (TCA). Also, we
thank the following organizations for connecting
us with individuals in long-term recovery for
CASA Columbia's online survey of this
population: Hazelden, Freedom Institute, Faces
and Voices of Recovery, Betty Ford Center,
National Council on Alcoholism and Drug
Dependence, Inc. (NCADD), Treatment
Communities of America (TCA), Alcoholism
and Substance Abuse Providers of New York
State, Inc. (ASAP) and an anonymous treatment
program alumni group. Finally, we are grateful
to the 1 76 key informants who shared their
insight and recommendations.
Susan E. Foster, MSW, CASA Columbia's Vice
President and Director of Policy Research and
Analysis, was the principal investigator and staff
director for this effort. The senior research
-iii-
manager was Linda Richter, PhD, Associate
Director of the Division and CASA Columbia
Scholar. The data collection and analysis was
conducted by CASA Columbia's Data Analysis
Center (SADACSM), headed by Roger Vaughan,
DrPH, CASA Columbia Fellow and Professor of
Clinical Biostatistics, Department of
Biostatistics, Mailman School of Public Health
at Columbia University, and associate editor for
statistics and evaluation for the American
Journal of Public Health. He was assisted by
Elizabeth Peters and Sarah Tsai, MA. Emily
Feinstein, JD, senior policy analyst, assisted
with the research and writing. Other research
staff members who worked on the project are:
Nina Lei, Mark Stovell, Akiyo Kodera, Dina
Feivelson, PhD, Gina Hijjawi, PhD, Harold
Wenglinsky, PhD, Swapna Reddy, JD, Kristen
Keneipp, MHS, Nabil Ansari and Sarah
Blachman. David Man, PhD, MLS, is CASA
Columbia's librarian; he was assisted by Barbara
Kurzweil. Jennie Hauser managed the
bibliographic database and Jane Carlson handled
administrative details.
While many individuals and institutions
contributed to this effort, the findings and
opinions expressed herein are the sole
responsibility of CASA Columbia.
Chapter I
Introduction and Executive Summary
A large and growing body of scientific research
has demonstrated clearly that addiction
involving nicotine, alcohol, illicit drugs and
controlled prescription drugs is a complex brain
disease.1 It affects 15.9 percent of the United
States population ages 12 and older (40.3
million)1 2— more than the share of the
population with heart disease,* diabetes or
cancer.3 Another 3 1 .7 percent of the population
(80.4 million), while not addicted, engages in
risky use§ of addictive substances in ways that
threaten health and safety.4
In this report, we have used the general term
addiction to apply to those who meet criteria for past-
month nicotine dependence based on the Nicotine
Dependence Syndrome Scale (NDSS) and those who
meet diagnostic criteria for past year alcohol and/or
other drug abuse or dependence (excluding nicotine)
in accordance with the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV). (The DSM,
the most widely accepted diagnostic system in the
U.S. for such conditions, refers to substance abuse
and substance dependence collectively as substance
use disorders. The diagnostic criteria for nicotine
dependence in the NDSS parallel those of the DSM-
IV). This definition is consistent with the current
move to combine abuse and dependence into an
overarching diagnosis of addiction in the upcoming
DSM-V. The term addiction also has been used in
reference to compulsive behaviors involving eating,
gambling and other activities that affect the brain's
reward system and which may develop independent
of or in combination with other manifestations of
addiction. This report, however, focuses only on
addiction involving nicotine, alcohol and other drugs.
* This estimate excludes the institutionalized
population, for which rates of addiction are higher.
* Includes coronary heart disease, angina pectoris,
heart attack or any other heart condition or disease,
excluding hypertension and stroke.
§ Risky users of addictive substances are defined in
this report as those who currently use tobacco
products, exceed the U.S. Department of Agriculture
(USDA) Dietary Guidelines for safe alcohol use,
misuse controlled prescription drugs, use illicit drugs,
or engage in some combination of these forms of
substance use, but do not meet clinical diagnostic
criteria for addiction. (See page 5.)
-1-
Addiction and risky use constitute the largest
preventable and most costly health problems
facing the U.S. today.5 It is estimated that more
than 20 percent of deaths in the U.S. are
attributable to tobacco, alcohol and other drug
use.6 Addiction and risky use cause or
contribute to more than 70 other conditions
requiring medical care, including cancer,
respiratory disease, cardiovascular disease,
HIV/AIDS, pregnancy complications, cirrhosis,
ulcers and trauma.7 They also drive and
contribute to a wide range of costly social
consequences, including crime, accidents,
suicide, child neglect and abuse, family
dysfunction, unplanned pregnancies and lost
productivity.8 Costs of addiction and risky
substance use to government alone total at least
$468 billion each year.9
While both addiction and risky use of addictive
substances contribute to these consequences,
they are very different conditions. Addiction is
a disease and, like other diseases, it can and
should be diagnosed and treated in the context of
the medical system, using available evidence-
based practices. Risky use of addictive
substances is a public health problem and tools
are available for a wide range of professionals in
the health, social services, education, criminal
justice and other sectors to screen for it and
intervene to reduce it and its consequences,
including the potential development of
addiction.
Despite the prevalence of these conditions, the
enormity of the consequences that result from
them and the availability of effective solutions,
screening and early intervention for risky
substance use is rare and the vast majority of
people in need of addiction treatment do not
receive anything that approximates evidence-
based care. Nine out of 10 people (89. 1 percent)
who meet diagnostic criteria for addiction
Involving interdisciplinary teams of physicians (of
multiple medical specialties and subspecialties),
nurses, physician assistants, nurses and nurse
practitioners and graduate-level clinical mental health
professionals (psychologists, social workers,
counselors), working collaboratively with auxiliary
and support personnel.
involving alcohol and drugs other than nicotine
report receiving no treatment' at all;10 as a
society, we do not even collect information on
the number of people receiving treatment for
addiction involving nicotine. There is no other
disease that affects so many people, has such
far-reaching consequences and for which there is
such a broad range of effective interventions and
treatments that is as neglected as the disease of
addiction.
This report documents the significant body of
evidence defining and describing the disease of
addiction and the risky use of addictive
substances. It reveals the size and shape of the
populations in need of screening, intervention
and treatment. It reviews the evidence of
effective screening, intervention, diagnostic,
treatment and disease management tools and
therapies. It outlines the consequences and costs
of our failure to prevent risky substance use and
treat addiction effectively. Finally, it examines
the profound gaps between those who need
treatment and those who receive it, and between
the services they receive and what constitutes
quality care.
Key factors driving these gaps include:
• Inadequate Integration of Addiction Care
into Mainstream Medical Practice:
Addiction prevention and treatment are for
the most part removed from routine medical
practice.11 In spite of the fact that about 80
percent of Americans1 visited at least one
physician or other health care professional in
* Treatment is defined in this report as psychosocial
and pharmaceutical therapies. Detoxification, mutual
support programs, peer counseling, other support
services (including religious-based counseling) and
services received in an emergency department are
excluded from the definition. Services provided in
prison or jail settings also are excluded since they
cannot be identified in the data sources used for this
analysis; furthermore, in CAS A Columbia's 2010
report {Behind Bars Update: Substance Abuse and
America 's Prison Population), more than 70 percent
of those receiving addiction-related services in
prisons and jails received support services rather than
any form of professional treatment.
* Ages 1 8 and older.
-2-
the past year, and more than two-thirds of
people with addiction are estimated to be in
contact with a primary or emergency care
physician about twice a year,13 most
physicians and other health professionals
do not identify or diagnose the disease or
know what to do with patients who present
with identifiable and treatable signs and
symptoms. And, unlike other diseases,
physicians too often lack access to available,
trained and certified addiction physician
specialists for consultation or referral.
Instead of addressing addiction, the medical
field primarily has focused its efforts on
treating the secondary and tertiary
complications of addiction, allowing the
public health epidemic to advance
unchecked. Furthermore, whereas the main
criterion for determining whether health care
services should be provided to patients in
mainstream medicine is the principle of
medical necessity,14 patients needing
addiction treatment may face stringent
eligibility criteria for treatment entry,
including insurance benefit restrictions,
limited availability of treatment slots, long
waiting lists, lack of child care and the
requirement to comply with all rules and
treatment protocols.15 There simply is no
other disease where appropriate medical
treatment is not provided by the health care
system and where patients instead must turn
to a broad range of practitioners largely
exempt from medical standards.
• Inadequate Education and Training of
Addiction Treatment Providers: The
majority of those who currently make up the
addiction treatment provider workforce are
not equipped with the knowledge, skills or
credentials necessary to provide the full
range of evidence-based services to treat the
disease.
The term "health professional" as used in this report
includes medical professionals (physicians, physician
assistants, nurses and nurse practitioners, dentists,
pharmacists) and graduate-level clinical mental
health professionals (psychologists, social workers,
counselors).
> Addiction counselors, who make up the
largest share of providers of addiction
treatment services, provide care for
patients with a medical disease yet they
are not required to have any medical
training and most states do not require
them to have advanced education of any
sort.'
> Physicians and other medical
professionals, who make up the smallest
share of providers of addiction treatment
services, receive little education or
training in addiction science, prevention
and treatment.
• Inadequate Accountability for Addiction
Treatment Providers: Addiction treatment
providers, facilities and programs are not
adequately regulated or held accountable for
providing treatment consistent with medical
Only six states require a bachelor's degree and only
one state requires a master's degree.
Published in the
American Journal of Public Health
July, 1919
There is urgent need for widespread and early
education of the medical profession,
legislators, administrative authorities and laity
into the facts of addiction disease. . .
As a definite clinical entity of physical
disease, addiction is practically untaught in
the school and unappreciated by the average
medical man. . .
In the light of available clinical information
and study and in the light of competent
laboratory research we are forced as a
profession to admit that we have not treated
our addiction sufferers with sympathetic
understanding and clinical competency and
that the blame for the past failure to control
the [narcotic] drug problem rests largely upon
the educational inadequacy of our medical
profession, and institutions of scientific and
public health education.16
-Ernest S. Bishop, MD, FACP
-3-
standards and proven treatment practices.
The credentials of treatment providers vary
dramatically from state to state and from
program to program. Compounding the
problem, quality assurance standards that do
exist focus more on administrative processes
than on measureable patient outcomes.
• Inadequate Allocation of Financial
Resources: Financial investments in
addressing addiction and risky substance use
are aimed disproportionately at coping with
their costly health and social consequences
rather than at the effective implementation
of available prevention, intervention and
treatment approaches. In 2010, only 1.0
percent ($28.0 billion) of total health care
costs went to treating the disease of
addiction.17 Spending on addiction
treatment disproportionately falls to the
public sector. In contrast to the role of
private insurance in general health care
spending-where it covers 54.4 percent of
costs-private insurers cover only 20.8
percent of the costs of addiction treatment,
and the private share has been decreasing.18
This profound gap between the science of
addiction and current practice related to
prevention and treatment is a result of decades
of marginalizing addiction as a social problem
rather than treating it as a medical condition.
Much of what passes for "treatment" of
addiction bears little resemblance to the
treatment of other health conditions. Much of
what is offered in addiction "rehabilitation"
programs has not been subject to rigorous
scientific study and the existing body of
evidence demonstrating principles of effective
treatment has not been taken to scale or
integrated effectively into many of the treatment
programs operating nationwide. This is
inexcusable given decades of accumulated
scientific evidence attesting to the fact that
addiction is a brain disease with significant
behavioral components for which there are
effective interventions and treatments. It also is
unfair to the thousands of addiction counselors
who struggle, in the face of extreme resource
limitations and no medical training, to provide
help to patients with the disease of addiction and
numerous co-occurring medical conditions.
America's tendency to frame risky use of
addictive substances and addiction as the same
issue and as moral or social problems has
resulted in an unmitigated failure on the part of
policymakers and the health care community to
educate the public about these health problems
in ways that can help prevent them and to offer
effective interventions and treatments that match
those offered for other health conditions; instead
the focus has weighed heavily toward law
enforcement. The end result is that we have
declared war on drugs rather than mounting a
rational approach to prevention, treatment and
finding a cure for the disease of addiction. We
largely have punished rather than treated those
in need of help even though treatment for a
disease and accountability for behavior are not
antithetic concepts.
It is long past time for health care practice to
catch up with the science. Failure to do so is a
violation of medical ethics, a cause of untold
human suffering and a profligate misuse of
taxpayer dollars.
The CASA Columbia Study
Substance use can be understood as a continuum
ranging from having never used tobacco, alcohol
or another drug at one end to having an
unmanaged chronic, relapsing disease' at the
other. (Figure LA)
Including any use of illicit drugs or the misuse of
controlled prescription drugs.
f This continuum focuses on substance use; the
category labeled addiction includes those individuals
who meet current clinical criteria for this disease but
does not include all individuals with addiction.
-4-
Figure 1 .A
Continuum of Substance Use
Percent of Population Age 12+
by Level of Substance Use*
12.7
25.2
14.5
31.7
Never
Used
No
Current
Use
Non-
Risky Use
Risky
Use
* Includes tobacco, alcohol, illicit drugs and misuse of
controlled prescription drugs.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 201 0.
Guidelines for safe alcohol use/ 20 misuse
controlled prescription drugs,5 use illicit
drugs" 21 or engage in some combination of
these forms of substance use but do not
meet clinical diagnostic criteria for
addiction. Risky use can result in
devastating and costly health and social
consequences including the disease of
addiction. Risky users are targets for public
health efforts aimed at reducing risky use
and for health professionals' efforts to
prevent risky use from progressing to the
disease of addiction. Approximately one-
third (31.7 percent) of the U.S. population
ages 12 and older (80.4 million people) are
risky substance users.22
While this report focuses primarily on those with
the disease of addiction, it makes an important
distinction between addiction and risky use of
addictive substances:
• Those with the active disease of addiction*
are defined in this report as meeting the
clinical diagnostic criteria for past month
nicotine dependence or past year alcohol
and/or other drug abuse or dependence.
Individuals who meet diagnostic criteria for
addiction are targets for appropriate,
evidence-based clinical interventions by
physicians and other health professionals.
Addiction afflicts 15.9 percent of the U.S.
population ages 12 and older (40.3 million
people).19
• Risky users of addictive substances are
defined in this report as those who currently'
use tobacco products, exceed the U.S.
Department of Agriculture (USDA) Dietary
Available data allow us to include only those who
meet behavioral criteria in accordance with the
diagnostic standards, meaning in most cases that their
disease is not currently being managed. Individuals
who have the disease of addiction but do not meet
diagnostic criteria for past month (nicotine) or past
year (alcohol and other drug) addiction are not
included.
1 In the past 30 days.
1 The U.S. Department of Agriculture Dietary
Guidelines for safe alcohol use are no more than one
drink a day for women, no more than two drinks a
day for men and no alcohol consumption for:
(1) persons under the age of 21; (2) pregnant women;
(3) individuals who cannot restrict their drinking to
moderate levels; (4) individuals taking prescription or
over-the-counter medications that can interact with
alcohol; (5) individuals with certain specific medical
conditions (e.g., liver disease, hypertriglyceridemia,
pancreatitis); and (6) individuals who plan to drive,
operate machinery, or take part in other activities that
require attention, skill or coordination or in situations
where impaired judgment could cause injury or death
(e.g., swimming). Due to data limitations, we were
unable to include categories 4-6 in our calculation of
risky drinkers.
§ For data analysis purposes, the national survey
examined for this report defines misuse of controlled
prescription medications more generally as "taking a
controlled prescription drug not prescribed for you or
taking it in a manner not prescribed for the
experience or feeling it causes." The misuse of over-
the-counter medications also constitutes risky use;
however, rates of risky use in this report do not
include the misuse of these medications since they
are not directly measured in the national surveys that
were analyzed for this study.
Substances controlled (either through prohibited or
restricted use) through the federal Controlled
Substances Act of 1970, which created a system for
classifying illicit and prescription drugs according to
their medical value and their potential for misuse. In
this analysis, illicit drugs include marijuana/hashish,
cocaine/crack, heroin, hallucinogens, Ecstasy,
methamphetamine and inhalants.
-5-
To document the research on the causes,
consequences and extent of risky substance use
and addiction; the available tools for effective
interventions and for treatment; the gap between
the need for such interventions and treatments
and the actual standard of care; the driving
forces behind this substantial gap; and to
develop concrete recommendations for
minimizing it, CASA Columbia conducted:*
• A thorough review of more than 7,000
scientific articles, reports, books and other
reference materials related to the science of
addiction, the consequences of risky use and
addiction, the prevention of risky use and
treatment of addiction and barriers to
improved care (see Appendix A);
• Secondary analysis of five national data sets
(see Appendix A);
• Interviews with and suggestions from 176
leading experts in a broad range of fields
relevant to the report, including researchers,
physicians and other health professionals,
other treatment providers, policymakers and
members of professional associations,
advocacy organizations, health insurers,
pharmaceutical companies and organizations
of people with the disease of addiction.
Whereas the majority of these experts
provided their thoughts in the context of an
open-ended interview guide designed by
CASA Columbia to explore key themes
related to this project, some provided advice,
suggestions and feedback about specific
content to be included in this report (see
Appendices A and B);
• Focus groups and a national general
population survey assessing the attitudes and
beliefs of 1,303 adults with regard to
addiction and its treatment: the National
Addiction Belief and Attitude Survey
(NABAS) (see Appendices A and C);
• Two statewide surveys of addiction
treatment providers in New York: one of 83
program directors and one of 141 staff
treatment providers (see Appendices A, D
and E);
• A national panel of treatment providers and
an online survey of 1,142 members of
professional associations involved in
addiction care (see Appendices A and F);
• An online survey of 360 individuals with a
history of addiction who are managing the
disease (see Appendices A and G);
• An in-depth analysis of state and federal
governments' and professional associations'
licensing and certification requirements for
individual treatment providers and addiction
treatment facilities and programs, as well as
accreditation requirements for facilities and
programs (see Appendix A); and
• A case study of addiction treatment in New
York State and New York City that drew
from the research described above and the
findings of which are incorporated into the
report where relevant (see Appendix A).
Key Findings
Addiction Is a Brain Disease
Addiction is a complex brain disease with
significant behavioral characteristics.23
Nicotine, alcohol, illicit drugs and controlled
prescription drugs all affect the pleasure and
reward circuitry of the brain in similar ways.24
Over time, continued use of these substances can
physically alter the structure and function of the
brain, dramatically affect judgment and
behavior25 and drive a compulsion to obtain and
use them, even in the face of mounting negative
consequences.26 Growing evidence also points
to structural and functional differences in the
brain and to genetic factors that may predispose
certain individuals to addiction.27
See Appendix A for a more detailed description of
the key methodological components of the study.
-6-
As with Other Health Conditions, There
Are Clear Risk Factors for the
Development of Addiction
Risk factors for developing addiction include a
genetic predisposition, structural and functional
brain vulnerabilities, psychological factors and
environmental influences. Whereas biological,
psychological and environmental factors— such
as impairments in the brain's reward circuitry,
compensation for trauma and mental health
problems, easy access to addictive substances,
substance use in the family or media and peer
influences— play a large role in whether an
individual starts to smoke, drink, or use other
drugs,28 genetic factors are more influential in
determining who develops the disease of
addiction.29 A factor that is particularly
predictive of risk, however, is the age of first
use; in 96.5 percent of cases, addiction
originates with substance use before the age of
2 1 30 when the brain is still developing and is
more vulnerable to the effects of addictive
substances.* 31
Addiction Frequently Co-Occurs with
Other Health Conditions
Addiction frequently co-occurs with, contributes
to or causes a wide range of medical conditions.
Both risky substance use and addiction cause or
contribute to more than 70 other conditions
requiring medical care, such as heart disease and
cancer,32 as well as mental health and behavioral
disorders-including depression, anxiety, post-
traumatic stress disorder, bipolar disorder,
schizophrenia and other neuropsychiatric
disorders.33
Addiction Can Be a Chronic Disease
There is tremendous variation in the severity and
course of the disease of addiction and of its
symptoms. Some individuals may experience
one episode in which their symptoms meet
clinical diagnostic criteria for addiction and be
non- symptomatic thereafter.34 In many cases,
These individuals also might have a predisposition
to develop addiction, irrespective of their actual use
of addictive substances.
however, addiction manifests as a chronic
disease-a persistent or long-lasting illness—
which requires ongoing professional treatment
and management.35 However, very few people
with addiction actually receive adequate,
effective, evidence-based treatment,36 and the
usual approach to treatment involves brief,
episodic interventions rather than a model based
on long-term chronic disease management. As a
result, high rates of relapse, while comparable to
other chronic diseases, may be due at least in
part to inadequate or ineffective interventions
and treatments.37
A Lack of Standardized Terminology
Compromises Effective Interventions
Terms used to describe different levels of
involvement with addictive substances— such as
experimentation, use, misuse, excessive use,
abuse, dependence and addiction—lack
precision, obscuring important differences in the
nature and severity of the illness and
complicating our ability to intervene and treat it
effectively. Even the word "treatment" lacks
precision with regard to addiction, since
historically it has been used to refer to a host of
interventions, many of which are not based in
the clinical and scientific evidence as are
treatments for other diseases.
Multiple Addictive Substances and
Behaviors Frequently Are Involved in
Risky Use and Addiction
Traditionally, risky substance use and addiction
have been addressed largely on a substance-
specific basis. Growing understanding of the
nature of risky use and the disease of addiction-
including the risk factors, symptoms and the
neuropsychological effects of addictive
substances-helps to explain the significant
proportion of risky users and those who are
addicted who are involved with more than one
addictive substance. Among risky substance
users who do not meet diagnostic criteria for
addiction, 30.6 percent are risky users of more
than one substance. Among those who are
addicted, 55.7 percent are risky users of one or
-7-
more other substances and 17.3 percent have
addiction involving multiple substances.38
Emerging research also suggests that other
behavioral manifestations of addiction (e.g.,
obesity, gambling, sexual addiction) share
common neuropsychological and genetic
pathways with addiction involving substances,39
underscoring the importance of treating the
antecedents, manifestations and consequences of
addiction more generally. When treatments are
too highly focused on a specific addictive
substance or behavior, they may not be
addressing the actual underlying disease of
addiction or the possibility of addiction
substitution, where a patient may replace one
form of addiction with another.40
Public Attitudes about the Causes of
Addiction Are Out of Sync with the Science
CASA Columbia's national survey of the
attitudes and beliefs of adults in the U.S. with
regard to addiction and its treatment (the
NABAS) found that while there is public
recognition of the role of genetics and biological
factors in the development of addiction,
approximately one-third of Americans continue
to view addiction as a sign of lack of will power
or self-control.41
Physicians and Other Health Professionals
Should Be on the Front Line Addressing
this Disease
As with other diseases, addiction should be
addressed within the medical system by
physicians (including multiple medical
specialties and sub-specialties) and a multi-
disciplinary team of health professionals
including physician assistants, nurses and nurse
practitioners, and graduate level clinical
psychologists, social workers and counselors.
In order to treat addiction and reduce risky
substance use and the related consequences,
physicians and other health professionals must:
• Understand the risk factors, how these risks
vary across the lifespan, how risky
substance use that does not result in
addiction has far-reaching adverse
consequences and that addiction frequently
co-occurs with other health conditions;
• Educate patients, and their families if
relevant, about these risks, the nature of the
disease of addiction and the adverse
consequences of risky substance use;
• Screen for risky substance use and
symptoms of addiction and co-occurring
health conditions using tools that have been
proven to be effective;
• Provide brief interventions when
appropriate; and
• Treat and manage the disease or provide
referrals to specialty care if needed.
Non-laboratory-based screening for risky
substance use can be conducted by a wide range
of trained health professionals and brief
interventions can be conducted by physicians
and by appropriately trained clinicians,
supervised as necessary. All aspects of
stabilization and treatment— including
laboratory-based screening, assessment, acute
care and disease management-should be
managed by a physician, as is the case with
other medical illnesses. Highly-trained clinical
mental health professionals can provide
psychosocial therapies as part of a treatment
plan established and managed by the patient's
physician. Case management can be provided
by nurses and nurse practitioners, physician
assistants and clinical mental health
professionals if appropriately trained in
addiction and if the services are performed under
the supervision of a physician. Paraprofessionals
and non-clinically trained and credentialed
counselors can provide auxiliary services as part
of a comprehensive treatment and disease
management plan.
-8-
Referrals to specialty addiction care should be
made to trained and credentialed addiction
physician specialists.* 42
Screening and Intervention Are Effective
at Addressing Risky Substance Use and
Forestalling Addiction
Screening and brief interventions have been
found to be effective tools for addressing the
risky use of tobacco,43 alcohol,44 illicit drugs and
controlled prescription drugs45 in multiple
settings and in many population groups 46
A range of screening tools exist and typically
include written or oral questionnaires and, less
frequently, clinical and laboratory tests.
However, most screening tools are substance
specific; an instrument that screens for risky use
or addiction involving all substances as a unified
dimension-and that makes appropriate
distinctions for age, culture and gender-has yet
to be developed.
For those who screen positive for risky
substance use that does not meet the threshold of
clinical addiction, a brief intervention-typically
involving motivational interviewing techniques
and substance-related education—is an effective,
low-cost approach to reducing risky substance
use.47
Effective Therapies to Treat and Manage
Addiction Exist
For individuals showing signs of addiction, a
comprehensive assessment of the stage and
severity of the disease and the provision of
treatment and disease management are critical to
improving health and preventing further health
and social consequences.48 As is true of other
chronic diseases, while all patients with
There are two major categories of addiction
physician specialists: physician experts in addiction
medicine— Diplomates of the American Board of
Addiction Medicine (ABAM)-and physician experts
in addiction psychiatry (psychiatrists with sub-
specialty certification in addiction psychiatry)—
Diplomates of the American Board of Psychiatry and
Neurology (ABPN).
addiction will not respond equally well to
treatment, the provision of evidence-based
treatment does increase the odds of success.
Addiction is a disease that can be treated and
managed effectively within the medical
profession using an array of evidence-based
pharmaceutical and psychosocial approaches. In
accordance with standard medical practice for
the treatment of other chronic diseases, best
practices for the effective treatment and
management of addiction must be consistent
with the scientific evidence of the causes and
course of the disease. Best practices require:49
• Comprehensive assessment of the extent
and severity of the disease, determination of
a clinical diagnosis, evaluation of co-
occurring health conditions and the
development of a tailored treatment plan;
• Stabilization of the patient's condition via
cessation of substance use and medically
supervised detoxification, when necessary,
as a precursor to treatment;
• Acute Care delivered by qualified health
care professionals via evidence-based
pharmaceutical and/or psychosocial
addiction treatments, accompanied by
treatment for co-occurring health conditions;
• Chronic Disease Management to help the
patient maintain the progress achieved
during acute treatment and prevent relapse.
The process should be medically supervised
and should involve pharmaceutical and/or
psychosocial therapies and continued
management of co-occurring health
conditions as indicated; and
• Support Services including the provision of
auxiliary services such as legal, educational,
employment, housing and family supports,
as well as nutrition and exercise counseling
and connection to mutual support programs.
-9-
The Importance of Tailored Interventions
and Treatment
Each life phase presents unique vulnerabilities
for risky substance use and the onset of the
disease of addiction. Recognizing these
differences as well as the basic risk factors for
each is critical to reducing risky substance use
and addiction.
Certain populations-such as pregnant women,50
the young51 and the elderly52— are more
vulnerable to the damaging and addictive effects
of tobacco, alcohol and other drugs. Among
members of the military exposed to combat,53
persons with co-occurring health conditions54
and individuals involved in the justice system55
the likelihood of addiction is significantly higher
than in the general population.
Treatment must be tailored to the particular
stage and severity of the disease, a patient's
overall health status, past treatments and any
other personal characteristics and life
circumstances that might affect patient
outcomes.56 These include patients with co-
occurring health conditions, adolescents,
women, older adults, racial and ethnic
minorities, individuals of minority sexual
orientation, veterans and individuals involved in
the justice system. The research evidence
clearly demonstrates that a one-size-fits-all
approach to addiction treatment typically is a
recipe for failure.57
Public Attitudes about Addiction Treatment
Reflect the Prevailing Non-Medical
Approach to Addiction Care
CAS A Columbia's NAB AS found that although
the American public appears to be supportive of
assuring that individuals with addiction receive
effective addiction treatment, public views about
what constitutes addiction treatment do not
comport with the science: more than half (60. 1
percent) of respondents to the NABAS
spontaneously offered mutual support programs
such as AA or NA as a "treatment" intervention
when asked what kinds of treatment come to
mind when they think about treatment for
addiction, despite the fact that such programs,
while very helpful sources of support to many
individuals with addiction, are not evidence-
based treatments for the disease.59 The public
also does not seem to distinguish between risky
substance use and the disease of addiction.
Most People in Need of Treatment Do Not
Receive It
As an indicator of the lack of attention afforded
the disease of addiction, no single national data
source exists to compare the proportion of the
population in need of addiction treatment
involving any addictive substance to the
proportion that receives such treatment. While
about seven out of 1 0 people with hypertension,
major depression or diabetes get treatment for
their medical conditions, only about one in 1 0
people with addiction involving alcohol or drugs
other than nicotine do,* 60 (Figure l.B), leaving a
treatment gap of 20.7 million individuals.61
No data exist on the treatment gap for those with
addiction involving nicotine. The proportion of
individuals in need of addiction treatment
involving alcohol and drugs other than nicotine
who actually receive it has changed little since
2002, when 9.8 percent of those in need received
treatment.62
For this comparison, CASA Columbia examined the
referenced national survey data to determine the
proportion of the population with each disease-those
with diagnosed or undiagnosed hypertension (59.3
million); those with diagnosed or undiagnosed
diabetes (25.8 million); those who met clinical
criteria for a major depressive episode in the past
year and/or received professional treatment (saw a
doctor, received medication, a combination thereof)
(22.4 million); and those who met clinical criteria for
addiction involving alcohol or other drugs excluding
nicotine in the past year and/or received professional
treatment for alcohol and/or other drugs in the past
year (23.2 million)-who received treatment.
-10-
Most Referrals to Publicly Funded
Treatment Come from the Criminal Justice
System
CASA Columbia's national survey conducted
for this study found that 46.8 percent of
respondents would turn to a health professional-
such as their physician (27.8 percent), a health
professional other than their primary care
physician (19.7 percent) or a mental health
professional (9.2 percent) —if someone close to
them needed help for addiction.63 However,
only 5.7 percent of referrals to publicly funded
treatment came from a health care provider. In
contrast, a full 44.3 percent of the referrals to
treatment were from the criminal justice
system,64 highlighting the fact that this disease
typically is addressed only at the point at which
it results in profound social consequences.
One-quarter (25.3 percent) of referrals came
from individuals, including concerned family
members, friends and the self-referred; 12.1
percent were referred by community sources
such as social welfare organizations, religious
organizations and mutual support programs; and
10.6 percent were referred by addiction
treatment providers for additional treatment.
Very few treatment referrals came from schools
(1.4 percent) or from employers (0.6 percent).65
(Figure l.C)
Figure 1 .B
Individuals with Select Medical Conditions
Who Receive Treatment
Hypertension1
Diabetes2
Major
Depression3
Addiction3
(excluding
Nicotine*)
1 Ages 18 and older; Ostchega, Y., Yoon, S.S., Hughes, J. & Louis, T.
(2008).
2 All ages; Centers for Disease Control and Prevention. (201 1).
3 Ages 1 2 and older; CASA Columbia analysis of The National Survey
on Drug Use and Health (NSDUH), 201 0
* Due to data limitations.
Figure 1.C
Sources of Referral to Publicly-Funded
Addiction* Treatment
Criminal Justice System
Individuals
Community Sources
Addiction Treatment Providers
Health Care Providers
Schools
* Excluding nicotine.
Source: CASA Columbia analysis of The Treatment Episode
Data Set (TEDS), 2009.
Some respondents chose more than one response, so
the 46.8 percent reflects those who chose either one
of these health professionals.
-11-
Less than Half of Treatment Admissions
Result in Treatment Completion
In 2008,* less than half (42.1 percent) of
discharges from formal addiction treatment
services were of admissions in which treatment
was completed.66 The highest completion rates
were from venues to which there were the
fewest admissions:
• 14.8 percent of admissions were to short-
term residential services which had the
highest completion rate of 54.8 percent;
• 11.4 percent of admissions were to longer-
term residential treatment which had a
completion rate of 45.5 percent; and
• 73.8 percent of admissions were to non-
residential services which had the lowest
completion rate of 39.1 percent.67
No data are available on the extent to which
referrals were based on matching providers with
individual treatment needs.
Patients Face Formidable Barriers to
Receiving Addiction Treatment
In addition to the lack of treatment referrals
from the health care system, many other barriers
stand in the way of individuals accessing and
completing addiction treatment. These include:
a misunderstanding of the disease, negative
public attitudes and behavior toward those with
the disease, privacy concerns, insufficient
insurance coverage of the costs of treatment,
lack of information on how to get help, limited
availability of services including a lack of
addiction physician specialists, insufficient
social support, conflicting time commitments,
negative perceptions of the treatment process
and legal barriers. Rarely is there only one
obstacle to a person receiving needed
treatment.68 Although comparable national data
for barriers to accessing smoking cessation
treatment are not available, research indicates
that barriers similar to those facing individuals
Most recent available data on discharges.
seeking treatment for addiction involving
alcohol or other drugs stand in the way of
smokers accessing tobacco cessation services.69
The Spending Gap
In 2010, the United States spent $43.8 billion to
treat diabetes70 which affects 25.8 million
people,71 $86.6 billion to treat cancer72 which
affects 19.4 million people73 and an estimated
$107.0 billion to treat heart conditions74 which
affect 27.0 million people,75 but only $28.0
billion to treat addiction which affects 40.3
million people.1 76 Looking just at government
spending, CASA Columbia calculated that in
2005, risky substance use- and addiction-related
spending accounted for 10.7 percent of federal,
state and local spending, and that for every
dollar federal and state governments spent, 95.6
cents went to pay for the consequences of
substance use; only 1.9 cents was spent on any
type of prevention or treatment/ The taxpayer
tab for government spending on the
consequences of risky substance use and
addiction alone totals almost $1,500 a year for
1 There are no national data that document spending
on treatment for addiction involving nicotine;
although the cost estimate of $28.0 billion applies to
the treatment of addiction involving alcohol or other
drugs excluding nicotine, the prevalence estimate of
those with addiction (40.3 million) includes those
with addiction involving nicotine.
* Due to data limitations, the prevalence estimates for
cancer and heart conditions include individuals ages
18 and older who have ever been told by a doctor or
other health professional that they have the condition
(cancer/malignancy or a heart condition). The
prevalence estimate for diabetes includes all ages and
the estimate for addiction includes individuals ages
12 and older; for diabetes and addiction, the
prevalence estimates include both diagnosed and
undiagnosed cases. In each case, total costs of
treatment are included without regard to age. The
cost estimates for treating diabetes, cancer and heart
conditions were inflated to 2010 dollars using the
medical inflation factor (7.9 percent) found in
SAMHSA's National Expenditures for Mental
Health Services and Substance Abuse Treatment,
1986-2005 publication.
§ In addition, 0.4 cents was spent on research, 1.4
cents on taxation or regulation and 0.7 cents on
interdiction.
-12-
every person in America. Nearly one-third
(32.3 percent) of all hospital inpatient costs are
attributable to substance use and addiction.78
Most Funding for Addiction Treatment
Comes from Public Sources
Spending on addiction treatment totaled an
estimated $28.0 billion in 2010. Whereas
private payers (including private insurers and
self-payers) are responsible for 55.6 percent
($ 1 .4 trillion) of medical expenditures in the
U.S., they are responsible for only 20.8 percent
($5.8 billion) of addiction treatment spending.79
The concentration of spending for addiction
treatment in public programs suggests that
insurance across the board does not adequately
cover costs of intervention and treatment,
resulting in costly health and social
consequences that stem from untreated addiction
and that fall disproportionately to government
programs. National data indicate that
individuals with private insurance are three to
six times less likely than those with public
insurance to receive specialty addiction
treatment.80
The Education, Training and
Accountability Gap
Compounding the profound gap between the
need for addiction treatment and the receipt of
such care is the enormous gulf between the
knowledge available about addiction and its
prevention and treatment and the education and
training received by those who provide or should
provide care. In spite of the evidence that
addiction is a disease:
• Most medical professionals who should be
providing addiction treatment are not
sufficiently trained to diagnose or treat it;
• Most of those who are providing addiction
treatment are not medical professionals and
are not equipped with the knowledge, skills
or credentials necessary to provide the full
range of evidence-based services to address
addiction effectively;81 and
• Addiction treatment facilities and programs
are not adequately regulated or held
accountable for providing treatment
consistent with medical standards and
82
proven treatment practices.
Further complicating this education, training and
accountability gap is the fact that there are no
national standards for the provision of addiction
treatment and instead considerable inconsistency
among states in the regulation of individual
treatment providers and of the programs and
facilities that provide addiction treatment
services.*
The Profound Disconnect between
Evidence and Practice
The prevention and reduction of risky substance
use and the treatment of addiction, in practice,
bear little resemblance to the significant body of
evidence-based practices that have been
developed and tested; indeed only a small
fraction of individuals receive interventions or
treatment consistent with scientific knowledge
about what works.83
Providing quality care to identify and reduce
risky substance use and diagnose, treat and
manage addiction requires a critical shift to
science-based interventions and treatment by
health care professionals— both primary care
providers and specialists.
Significant barriers stand in the way of making
this critical shift, including: an addiction
treatment workforce starved of resources,
operating outside the medical profession and
lacking capacity to provide the full range of
evidence-based practices including necessary
medical care; a health professional that should
be responsible for providing addiction screening,
interventions, treatment and management but
does not implement evidence-based addiction
care practices; inadequate oversight and quality
assurance of treatment providers and
intervention practices; limited advances in the
With the notable exception of the regulation of
medication-assisted therapy for addiction involving
opioids.
-13-
development of pharmaceutical treatments and
the adoption of existing pharmaceutical
therapies; and a lack of adequate insurance
coverage.
Recent efforts by government agencies and
professional associations have begun to tackle
these challenges to closing the evidence-practice
gap, but are simply insufficient.
Nothing short of a significant overhaul in current
approaches is required to bring practice in line
with the evidence and with the standard of care
for other public health and medical conditions.
Given the prevalence of risky substance use and
addiction in America and the extensive evidence
on how to identify and address them, continued
failure to do so raises the question of whether
the insufficient care that patients with addiction
usually do receive constitutes a form of medical
malpractice. It also signals widespread system
failure in health care service delivery, financing,
professional education and quality assurance.
Recommendations and Next Steps
It is time for health care practice to catch up
with the science. There is no silver bullet to
making this happen; instead, a broad set of
comprehensive reforms must be put in place.
Toward this end, CASA Columbia makes the
following recommendations:
Reform Health Care Practice
• Incorporate screening and intervention
for risky substance use, and diagnosis,
treatment and disease management for
addiction into routine medical practice.
As essential components of routine medical
care, all physicians and other medical
professionals should provide their patients
with addiction-related screening and, as
needed: brief interventions; comprehensive
assessment to determine disease stage,
severity and the presence of co-occurring
health conditions; stabilization; acute
treatment; chronic disease management; and
connection to support and auxiliary services.
Patients with severe cases of addiction
should be referred to an addiction physician
specialist.
• All medical schools and residency
training programs should educate and
train physicians to address risky
substance use and addiction. All
physicians should be educated and trained in
the origins of risky substance use and
addiction; prevention, intervention,
treatment and management options; co-
occurring conditions; and special population
and specialty-care needs. These core
clinical competencies should be required
components of all medical school curricula,
medical residency training programs,
medical licensing exams, board certification
exams and continuing medical education
(CME) requirements, including maintenance
of certification programs.
• Require non-physician health
professionals to be educated and trained
to address risky substance use and
addiction. Develop core clinical
competencies in addressing risky use and
preventing and treating addiction for each
type of non-physician health professional
including, physician assistants, nurses and
nurse practitioners, dentists, pharmacists and
graduate-level clinical mental health
professionals (psychologists, social workers,
counselors). Assure that these core clinical
competencies and specialized training are
required components of all professional
health care program curricula, graduate
fellowship training programs, professional
licensing exams and continuing education
(CE) requirements. Require all non-
physician health professionals providing
psychosocial addiction treatment services to
have graduate- level clinical training in
delivering these services. Require that all
pharmaceutical treatments for addiction be
provided only by a physician or in
accordance with a treatment plan managed
by a physician.
• Develop improved screening and
assessment instruments. Screening
instruments should be adjusted or developed
-14-
to coincide with appropriate definitions of
risky substance use, and assessment
instruments should be adjusted or developed
to mirror diagnostic criteria for addiction.
Both screening and assessment instruments
should address all types of addictive
substances.
• Establish national accreditation
standards for all addiction treatment
facilities and programs that reflect
evidence-based care. As a condition of
accreditation, accrediting organizations
should stipulate requirements for all
facilities and programs providing addiction
treatment with regard to professional
staffing (e.g., requiring them to have a full-
time certified addiction physician specialist
on staff to serve as medical director, oversee
patient care and be responsible for all
treatment services), intervention and
treatment services (e.g., requiring them to
provide comprehensive assessment and
evidence-based treatment for addiction
involving all substances that is tailored to
the stage and severity of the disease, co-
occurring conditions and patient
characteristics), and quality assurance (e.g.,
requiring them to collect and report
comprehensive quality assessment data,
including process and outcome
measurements).
• Standardize language used to describe the
full spectrum of substance use and
addiction. Recognize addiction as a
primary medical disease and standardize the
language related to the spectrum of
substance use severity in current and
forthcoming diagnostic instruments.
Develop a classification system based both
on observable behavior and neurobiological
measures that underlie different
manifestations of addiction and related
conditions which currently are classified and
addressed as distinct conditions.
Use the Leverage of Public Policy to Speed
Reform in Health Care Practice
• Condition grants and contracts for
addiction services on the provision of
quality care. Federal, state and local
governments should require-as a condition
of receipt of public funds-that grants,
contracts and non-insurance reimbursement
for addiction treatment services utilize
evidence-based prevention and treatment
approaches, including pharmaceutical
therapies (provided or managed by a
physician demonstrating the core
competencies of addiction medicine or
addiction psychiatry) and psychosocial
therapies (provided by medical professionals
or graduate-level clinical mental health
professionals trained and licensed in the core
competencies of addiction treatment), as
indicated; involve other health professionals,
individuals providing auxiliary services and
those providing peer support, working in a
multidisciplinary team; and generate
positive and measurable long-term patient
outcomes.
• Educate non-health professionals about
risky substance use and addiction.
Require that the topic of risky substance use
and addiction be included in the education
and training of government- funded
professionals who do not provide direct
addiction-related services but who come into
contact with significant numbers of
individuals who engage in risky substance
use or who may have addiction. These
include, but are not limited to law
enforcement and other criminal justice
personnel, legal staff, child welfare and
other social service workers and educators.
• Identify patients at risk in government
programs and services where costs of
risky use and addiction are high. Federal,
state and local governments should require
that routine screening and brief interventions
be provided by trained professionals in all
educational, mental health, developmental
disabilities, child welfare, housing, juvenile
-15-
justice and adult corrections services that
receive public funding; and that patients
who screen positive for risky use or a
potential diagnosis of addiction be
connected with a trained health professional
for intervention, diagnosis, treatment and
disease management.
Develop tools to improve service quality.
Federal and state governments in
collaboration with professional associations,
accrediting organizations and other non-
profit organizations focusing on health care
quality should develop and disseminate
evidence-based tools, practice guidelines
and performance measures oriented toward
patient outcomes to improve the quality of
addiction care (involving all substances) and
require their implementation as a condition
of continued licensure and/or accreditation.
License addiction treatment facilities as
health care providers. Federal, state and
local governments should subject all
addiction treatment facilities and programs
to the same mandatory licensing processes
as other health care facilities.
Require adherence to national
accreditation standards that reflect
evidence-based care. As a condition of
licensure, federal, state and local
governments should stipulate that all
facilities and programs providing addiction
treatment adhere to established national
minimum standards for accreditation.
Require that all insurers provide
coverage for comprehensive addiction
care. Require that all health insurers-
public and private— provide coverage for all
insured individuals for patient education,
screening and intervention for risky
substance use and treatment and
management of addiction (involving all
substances associated with addiction)
consistent with standards of medical
practice, eliminating exemptions. As a
condition of reimbursement, public payers
and private insurance companies should be
mandated to require that all addiction
interventions and treatment be directly
provided, supervised or managed by trained
medical professionals. Public payers and
private health insurance companies should
encourage participating providers and
facilities to adopt evidence-based practices,
institute quality-improvement measures and
assess patient outcomes. To help ensure
comprehensive coverage and appropriate
medical care, the Uniform Accident and
Sickness Policy Provision Law (UPPL),
which bars insurance coverage for injuries
sustained by a person who was under the
influence of alcohol or other drugs at the
time of the injury, should be eliminated.
• Expand the addiction medicine
workforce. Accelerate the work begun by
the American Board of Addiction Medicine
Foundation to develop residency training
programs in addiction medicine and secure
residency accreditation from the
Accreditation Council for Graduate Medical
Education (ACGME). Pursue and gain
recognition of addiction medicine by the
American Board of Medical Specialties
(ABMS). Support the efforts of ACGME-
accredited addiction psychiatry residencies
to increase the number of enrolled residents.
Through these actions, assure that addiction
medicine training programs are available to
physicians, that training opportunities within
addiction psychiatry are expanded, and that
such specialty care is formally recognized
and available in every hospital throughout
the country and through every health care
system.
• Implement a national public health
campaign. Implement a nationwide public
health campaign through federal agencies
charged with protecting the public health to
educate the public about all forms of risky
substance use and addiction.
• Invest in research and data collection.
Invest in research designed to improve and
track progress in addiction prevention,
treatment and disease management and to
find a cure for addiction.
-16-
Implement the National Institutes of
Health's (NIH) recommendation to create
a single institute addressing substance use
and addiction. Create a unified national
institute focused on substance use and
addiction, recognizing the overarching
disease of addiction rather than continuing
the focus on different manifestations of the
disease-tobacco, alcohol, other drug use—
and including the risky use of all addictive
substances. Include in the research portfolio
addiction involving behaviors other than
substance use, and focus on the causes,
correlates, consequences, interventions,
policies and possible cures for all
manifestations of the disease. The portfolio
of the institute also should include health
conditions resulting from risky use and
addiction and other conditions which
increase the risk of developing addiction.
-18-
Chapter II
What Is Addiction?
Addiction* is a complex brain disease with
significant behavioral characteristics. 1 In many
but not all cases, it involves the use of nicotine,
alcohol and other drugs. ' Addiction involving
these substances typically originates with use in
adolescence when the brain is still developing
and is more vulnerable to their effects.2 If
untreated, it can become a chronic and relapsing
condition, requiring ongoing professional
treatment and management.3
Although there has been an evolution in
scientific understanding of the disease, public
attitudes and health care practice have not kept
pace with the science. Terms used to describe
different levels of substance use and addiction's
many forms lack precision, obscuring important
differences in the use of addictive substances
and the nature and severity of the illness and
complicating our ability to treat it effectively.
In this report, we have used the general term
addiction to apply to those who meet criteria for past-
month nicotine dependence based on the Nicotine
Dependence Syndrome Scale (NDSS) and those who
meet diagnostic criteria for past year alcohol and/or
other drug abuse or dependence (excluding nicotine)
in accordance with the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV). (The DSM
refers to substance abuse and substance dependence
as substance use disorders. The criteria for nicotine
dependence in the NDSS parallel those of the DSM-
IV.) This definition is consistent with the current
move to combine abuse and dependence into an
overarching diagnosis of addiction in the upcoming
DSM-V.
1 Other drugs include federally controlled illicit drugs
and the misuse of controlled prescription drugs. The
term addiction also has been used in reference to
compulsive behaviors involving eating, gambling and
other activities that affect the brain's reward system
and which may develop independent of or in
combination with other manifestations of addiction.
This report, however, focuses only on addiction
involving nicotine, alcohol and other drugs.
-19-
Addiction Is a Brain Disease
Advances in neuroscientific research, including
animal studies and brain imaging, demonstrate
clearly that addiction is a primary and often
chronic disease of the brain.* 4 The risk factors
for developing the disease include a genetic
predisposition and a range of biological,
psychological and environmental influences.5
There is a growing body of evidence showing
the brain circuits that are implicated in substance
addiction in general also are involved in other
compulsive or addictive behaviors such as those
related to gambling, certain forms of disordered
eating (e.g., bulimia, obesity) and compulsive
sexual activity. For these reasons, researchers
are beginning to explore whether substance
addiction might be part of a syndrome
characterized by:
• Shared neurobiological and psychosocial
antecedents (risk factors);
• Production of desirable effects upon
involvement with the rewarding object or
activity;
• Shared manifestations and outcomes (e.g.,
biological ones such as tolerance or
withdrawal or behavioral or psychological
ones such as deceit, shame, guilt or
depression); and
• A shared course of the disease (e.g.,
improvement, relapse, remission and the
potential for progression to disability or
death).7
A primary disease indicates that it is not simply a
symptom or effect of another disease or condition.
The focus of this report is on addiction involving
nicotine, alcohol and other drugs. Use of these
substances can result from an existing brain
dysfunction; use also can alter the structure and
function of the brain, dramatically affecting
judgment and behavior.8 The amount and
duration of substance use that results in brain
changes and addiction depends on the individual
and the particular substances used. f 9
As yet, there is no conclusive biological marker
of addiction; therefore the diagnosis of addiction
is based on its symptoms including the
compulsive use of addictive substances,
significantly impaired function and persistent
use despite negative consequences.1 10 These
symptoms that characterize addiction are
cognitive and behavioral manifestations of the
underlying disease and its effects on the brain. 1 1
The foundations of the disease may exist in
certain individuals even before they ever use an
addictive substance and, in some cases, once the
disease develops it persists even when an
individual is not actively engaged in substance
1 The addictive potential of a substance is
determined not only by its intrinsic ability to
stimulate the reward circuits of the brain, but also by
the speed with which it crosses the blood-brain
barrier (i.e., how soon after initial
ingestion/injection/inhalation it reaches receptors in
reward circuits of the brain).
* Other physical signs such as intoxication,
withdrawal, needle-related findings, co-infections,
and laboratory findings— such as abnormalities in
liver function tests or positive breath or urine tests-
can aid in the diagnosis.
...addiction is not about drugs, it's about
brains. It is not the substances a person uses
that make them an addict; it is not even the
quantity or frequency of use. Addiction is about
what happens in a person 's brain when they are
exposed to rewarding substances or rewarding
behaviors, and it is more about reward circuitry
in the brain and related brain structures than it
is about the external chemicals or behavior that
"turn on " that reward circuitry. 14
Unfortunately, keeping the emphasis on just the
behavioral manifestations presumes that the
problem is present when the behavior is present
and the problem is resolved if the behavior is not
present for whatever duration of time, even
though the underlying disease process may be
present and even progressing, or contributing to
other manifestations, signs and symptoms that
may be overlooked. 13
-20-
The areas of the brain affected by this complex
disease are among those that are responsible for
survival-including the areas associated with
motivation, decision making, risk and reward
assessment, pleasure seeking, impulse control/
inhibition, emotion, learning, memory and stress
control.15
In order to reinforce activities necessary for
survival, the brain produces feelings of pleasure
in response to the satisfaction of fundamental
drives such as hunger, thirst and sex.16
Behaviors that lead to these rewards tend to be
reinforced and thus perpetuated over time.17 On
a neurological level, this reinforcement is a
process carried out by chemical messengers that
flood the reward circuits of the brain.18
Virtually all addictive substances affect the
pleasure and reward circuitry deep in the brain*
which is activated by the neurotransmitter
dopamine.' 19
* The mesolimbic reward system.
' The neurotransmitter serotonin also is involved in
some forms of substance addiction; it plays a role in
motivated or directed actions such as attaining
addictive substances and also influences dopamine
levels in the brain. Hallucinogenic drugs like LSD
and Ecstasy target serotonin systems in the brain.
Addictive substances drive behavior by causing
the release of more dopamine within brain
reward circuits than almost all natural rewards
including those tied to food and sex.20 With
repeated use of addictive substances, the brain
begins to expect this stimulation and an addicted
individual may experience intense desire or
cravings whenever the addictive substances are
not readily available and especially when the
individual is exposed to cues associated with
substance use.21 Recent research points to
evidence that use of one addictive substance can
increase the risk of use of and addiction
involving another substance; for example,
nicotine use can prime the brain, making it more
susceptible to developing addiction involving
cocaine.* 22 Signals in the environment such as
seeing a drug-using friend or passing a bar, or
emotional signals such as feeling stressed or sad
also become associated with the addictive
substance and spur the drive to obtain it.23
As use continues, the pleasure associated with
the dopamine release that results from the
ingestion of an addictive substance— or from its
anticipation-can become consuming to the point
where fundamental natural drives and associated
behaviors lose their value in comparison.25
At the same time, the brains of substance-using
individuals may adapt to the unnaturally high
levels of dopamine that result from continued
substance use and may respond by reducing the
normal release of dopamine as well as the
number of dopamine receptors in the brain.26
When this happens, the addictive substance may
become necessary just for the person to feel
normal.27 Compared to non-substance users, the
brains of chronic substance users appear to have
lower baseline levels of dopamine, making it
difficult for them to achieve feelings of pleasure
from substance use and other behaviors that
once were pleasurable.28
Changes in the function and structure of the
brain result in specific, compulsive behaviors
aimed at obtaining and using addictive
substances.29 The cognitive control of an
1 This study provides a biological mechanism for the
"gateway effect."
Definition of Addiction
American Society of Addiction Medicine
Addiction is a primary, chronic disease of brain
reward, motivation, memory and related circuitry.
Dysfunction in these circuits leads to
characteristic biological, psychological, social and
spiritual manifestations. This is reflected in an
individual pathologically pursuing reward and/or
relief by substance use and other behaviors.
Addiction is characterized by inability to
consistently abstain, impairment in behavioral
control, craving, diminished recognition of
significant problems with one's behaviors and
interpersonal relationships and a dysfunctional
emotional response. Like other chronic diseases,
addiction often involves cycles of relapse and
remission. Without treatment or engagement in
recovery activities, addiction is progressive and
can result in disability or premature death.24
-21-
addicted individual is so weakened that even
when he or she wants to cut down or stop using
an addictive substance, it becomes extremely
difficult to do so.30
People may choose to take drugs, but no one
chooses to be an addict.
-Participant
CASA Columbia Focus Group
May 2008, Philadelphia, PA
The Risk Factors for Addiction
Genetic factors play a major role in the
development of addiction as do individual
biological and psychological characteristics and
environmental conditions.31 These factors affect
both the initial use of an addictive substance and
the progression from initiation of substance use
to regular use to addictive use.32
Whereas biological, psychological and
environmental factors— such as impairments in
the brain's reward circuitry, compensation for
trauma and mental health problems, easy access
to addictive substances, substance use in the
family or media and peer influences-play a
large role in whether an individual starts to
smoke, drink or use other drugs,33 genetic
factors are more influential in determining who
progresses to risky use or addiction.34 A factor
that is particularly predictive of risk, however, is
the age of first use; almost all cases of addiction
begin with substance use before the age of 2 1 ,
when the brain is still developing.35
development of addiction. Although certain
specific genetic factors predispose an individual
to addiction involving a particular substance,37
genetic factors also appear to contribute
generally to the risk of use and addiction.38
Advances in genetic research have enabled
scientists to identify individual genes, including
genetic variations in components of the
dopamine transmission system,39 implicated
both in the likelihood of substance use and of
addiction involving a variety of substances.40
Genetic variations may affect a person's ability
to metabolize an addictive substance41 or to
tolerate it.42 Studies have found that genetics
account for between half and three quarters of
the risk for addiction. ' 43 Genetic factors appear
to be stronger drivers than environmental factors
of initiation of substance use at an early age.44
Nicotine. Adolescents who do not have a
certain variant of the gene that is responsible for
the enzyme that metabolizes nicotine* progress
from smoking to addiction involving nicotine
faster than adolescents with that type of gene.45
Other genetic variations in genes that determine
how nicotine receptors in the brain function5
also are linked to increased risk of addiction
involving nicotine and difficulty quitting
smoking.46
Alcohol. Individuals whose genetic makeup
influences them to have a higher tolerance for
alcohol are at increased risk of developing
Genetic Risks
Twin and adoption studies confirm a genetic
role in the likelihood of substance use and the
These studies help distinguish the roles of genetics
and environment in the development of addiction.
Studies of adopted children allow researchers to
compare the adopted child both to her biological
parents with whom she shares genetic features but no
environmental experiences and to her adopted parents
with whom she shares environmental experiences but
no genetic features. Studies of identical and fraternal
twins allow researchers to isolate genetic similarities
from environmental similarities. Identical twins are
genetically identical and fraternal twins share an
average of 50 percent of their genes, but both types of
twins typically experience a shared environment if
reared together.
f The majority of the genetics literature focuses on
addiction involving alcohol; the estimated extent of
genetic influence on addiction involving other drugs
varies by the type of drug.
* CYP2A6.
§ e.g., CHRNA5.
-22-
addiction. Adopted children with biological
parents who have addiction involving alcohol
are at least twice as likely as are adopted
children without such parents to develop
addiction involving alcohol.48 Individuals
whose genetic makeup produces involuntary
skin flushing and other unpleasant reactions to
alcohol are at reduced risk of developing
addiction involving alcohol.49
Other Drugs. Genetic influences have been
implicated in marijuana use51 and particular
genes have been associated with marijuana
cravings and withdrawal symptoms.52 Twin
studies have found genetic risks for
hallucinogen, opioid, sedative and stimulant use
and addiction.53
Biological Risks
In addition to genetic variations, certain
individuals have neurological, structural or
functional differences that make them more
susceptible to addictive substances.54 This is in
part due to individual differences in how the
brain produces and reacts to dopamine.55 Some
research indicates that individuals with a
naturally low level of dopamine response to
addictive substances are at increased risk of
engaging in substance use in order to achieve a
greater experience of reward. Other research
suggests that individuals with a biological
There is some indication that these individuals have
less cognitive impairment following the ingestion of
alcohol and, therefore, may not perceive the negative
experiential aspects of alcohol use in the same
manner as individuals whose brains are more strongly
affected by alcohol ingestion.
tendency toward heightened dopamine response
also are at increased risk because of their
enhanced or above average experience of reward
or pleasure from engaging in substance use.56
Other biological risks may involve damage or
deficits in the regions of the brain' responsible
for decision making and impulse control.57
Psychological Risks
Clinical mental health disorders such as
depression and anxiety and psychotic disorders
such as schizophrenia, as well as behavioral
disorders such as conduct disorder and attention-
deficit/hyperactivity disorder58— and sub-clinical
symptoms of these conditions59~are strongly
linked to substance use and addiction and to the
risk of transitioning from substance use to
addiction.60 Individuals whose brain
development has been altered by stress are more
sensitive to the effects of addictive substances
and more vulnerable to the development of
addiction.61 Likewise, individuals with post-
traumatic stress disorder (PTSD), common
among veterans and individuals in active
military duty, are at increased risk of developing
addiction.62 People who have risk-taking or
impulsive personality traits63 or who have low
self-esteem64 also are likelier to engage in
substance use65 as are victims of trauma or
abuse.66 Expectations play a role in substance
use as well, since people who expect that using
addictive substances will be a positive and
rewarding experience—in terms of physical
effects, mood or behavior— are likelier to smoke,
drink alcohol or use other drugs than are those
with more balanced or negative expectations.67
Environmental Risks
Many factors within an individual's family,
social circle and community, as well as the
larger cultural climate, increase the likelihood
that an individual will use addictive substances
and develop addiction.
' e.g., in the orbitofrontal cortex and anterior
cingulate cortex.
It's theoretically possible to take kids before
they first drink, find out whether they have any
gene variations, and say to them, 'If you choose
to be a drinker, then be careful because it's very
likely that you '11 need to drink more to have the
same effect. ' 50
-Marc A. Schuckit, MD
Distinguished Professor of Psychiatry
Department of Psychiatry
University of California, San Diego
-23-
People who grow up in homes in which parents
routinely expose their children to smoking,
excessive drinking or other drug use are at
increased risk of substance use, as are those
whose parents do not convey strong anti-
substance use messages and expectations.68 The
nature of the parent-child relationship is key;
people who come from families with high levels
of parent-child conflict, poor communication,
weak family bonds and other indicators of an
unhealthy parent-child relationship are at
increased risk of substance use and addiction.69
Individuals whose peers engage in substance use
or convey approval of such use are at increased
risk as well.70
The simple fact of availability of addictive
substances makes it likelier that an individual
will use them.72 Homes where liquor and
medicine cabinets are open to teens increase the
chances that teens will use these substances.73
People who live in communities where addictive
substances are readily available, where using
such substances is considered normal or
expected or where tobacco and alcohol retail
outlets are prevalent are at increased risk.74
Widespread access to controlled prescription
drugs contributes to the misuse of these
substances75 and increased access to marijuana
marketed as medicine is linked to increased
use.76 Community tolerance of high levels of
substance use or of experimenting with and
using addictive substances as a normal rite of
passage for adolescents also increases the risk of
use, as does lax enforcement of governmental
policies and regulations restricting use.77
Exposure to advertising and marketing messages
that promote or glamorize smoking and drinking
increases the chances that these substances will
be used and misused.78 Direct-to-consumer
marketing of controlled prescription drugs may
encourage substance use by conveying the
message that there is a pill for every ill.79
Environmental influences can exacerbate
existing genetic, biological and psychological
risks for substance use, further increasing the
chances that an individual will engage in risky
substance use, sometimes to the point of
addiction.80
Early Initiation of Use
Adolescence is the critical period of
vulnerability for the onset of substance use and
the development of addiction.81 In 96.5 percent
of cases, addiction originates with substance use
before the age of 21. 82 Because the parts of the
brain responsible for judgment, decision-
making, emotion and impulse control are not
fully developed until early adulthood,
adolescents are more likely than adults to take
risks, including experimenting with addictive
substances.83 At the same time, because these
regions of the brain are still developing, they are
more vulnerable to the negative impact of
addictive substances, further impairing
judgment, interfering with brain development
and increasing the risk of addiction.* 84 The
combination of early initiation of use and
genetic, biological, psychological or
environmental risk factors dramatically hike the
chances that addiction will develop.85
Adolescents with a genetic predisposition to
addiction and/or co-occurring mental health
problems are at the greatest risk of progressing
from substance use to addiction.86
... [addiction] is not simply a disease of the
brain, but it is a developmental disorder, and it
71
begins early in life— during adolescence.
-Nora D. Volkow, MD
Director
National Institute on Drug Abuse (NIDA)
Risky Use and Addiction
Frequently Co-occur with Other
Health Conditions
Individuals with addiction are likely to have co-
occurring health conditions.87 Smoking causes
bladder, esophageal, laryngeal, lung and oral
cancer.88 From 2000-2004, the top three causes
of smoking-attributable death were lung cancer,
As is true of much of health research, the research
on the neurological effects of addictive substances on
the adolescent brain primarily has been conducted on
animals.
-24-
ischemic heart disease and chronic obstructive
pulmonary disease.89 Alcohol consumption
contributes to diseases that are among the top
causes of death, including heart disease, cancer
and stroke.90 Addiction involving alcohol is
linked to cirrhosis, alcoholic hepatitis, chronic
pancreatitis, cardiomyopathy, heart arrhythmias,
stroke and neoplasms of the liver, pancreas and
esophagus.91 Heavy alcohol use and addiction
involving alcohol are associated with the
incidence and re-infection of tuberculosis.92
Injection drug use is a risk factor for infectious
diseases, including HIV, hepatitis C and
hepatitis B.93 The incidence of various forms of
cancer,94 heart disease95 and sexually-transmitted
diseases96 are higher among those with addiction
than among those without addiction.
Risky use and addiction also have high rates of
co-occurrence with many mental health
problems including depression, anxiety, post-
traumatic stress disorder, bipolar disorder,
schizophrenia and other neuropsychiatric
disorders such as attention deficit/hyperactivity
disorder, conduct disorder and eating
disorders.98 The association between addiction
and co-occurring health conditions can result
from several factors. Substance use may
precipitate the onset of other conditions such as
depression or anxiety disorders.99 Other times,
the health conditions may precede the onset of
addiction, as often occurs with mood disorders
and attention deficit/hyperactivity disorder,100 as
individuals attempt to self-medicate the pain or
distress associated with their illness.101 The two
types of conditions also may co-occur as a
function of an underlying psychological or
biological propensity, or substance use can
exacerbate or complicate symptoms of existing
health conditions.102
the risk of relapse. In these cases, addiction is a
chronic disease-like heart disease, hypertension,
diabetes and asthma— defined as having a clear
biological basis, a behavioral component,
environmental influences, unique and
identifiable signs and symptoms, a predictable
course and outcome and the need for continued
management following treatment.104
Like any other chronic condition, addiction
rarely abates after a single course of medication
or other treatment or after a single attempt to
alter one's lifestyle or behavior. As is true of
other chronic conditions, individuals with
addiction can have symptom-free periods and
periods of relapse.105 Many patients relapse
multiple times and still others never achieve
effective disease management.106 In fact,
addiction frequently is characterized as a disease
where relapse is virtually inevitable. Yet, this
conception of addiction might be due to the
focus of research studies on those with the most
severe manifestations of addiction, who
experience multiple episodes of symptom
relapse and co-existing health and social
problems over the course of many years or even
a lifetime.107 Furthermore, very few people with
addiction actually receive adequate, effective,
evidence-based treatment.108 The seemingly
high rates of relapse* may be due, at least in
part, to inadequate or ineffective interventions
and treatments.109
It's not surprising to us now that when you stop
the treatment, people relapse. It doesn 't mean
that the treatment doesn 't work, it just means
that you need to continue treatment.91
-Daniel Alford, MD, MPH
Associate Professor of Medicine
Boston University School of Medicine
Addiction Can Be a Chronic
Disease
Once an individual develops addiction, changes
in the brain's reward circuitry may remain even
after cessation of substance use.103 These
changes leave addicted individuals vulnerable to
physiological and environmental cues that they * Relapse rates for those with addiction are
have associated with substance use, increasing comparable to relapse rates for those with other
chronic diseases.
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Models for Understanding
Addiction
The model for how we understand addiction is
critical because it influences how individuals
with addiction are treated in society and guides
the nature of the services provided to address the
disease.110 The current model of addiction
recognizes that it is a complex brain disease111
and that multiple determinants and systems
influence substance use and its progression to
addiction.112 Although this model is based on a
large and growing body of scientific evidence,
treatment practice and public attitudes still
reflect earlier models of understanding the
condition.
Since the 1700s, with few exceptions,113 two
different models have dominated society's views
on addiction, driven in large part by
sociopolitical influences and also by developing
knowledge about the science of addiction. 1 14
The moral model of addiction framed addiction
primarily as a failure of personal responsibility
or morality. It asserted that addiction could be
addressed simply by requiring personal
responsibility and accountability on the part of
the person who is addicted. This approach has
contributed to:
• The stigma associated with addiction,
attaching blame to the individual, creating
shame and embarrassment, increasing the
likelihood of discrimination and decreasing
the chances that the addicted individual will
seek or receive effective treatment.115
• Restrictions in benefits for addicted
individuals. In 1995, a Congressional vote
discontinued Supplemental Security Income
(SSI) disability benefits to individuals
whose primary diagnosis was addiction
involving alcohol or other drugs.116 And,
the majority of states in the U.S. currently
are proposing or adopting legislation that
condition the receipt of public services
including welfare, unemployment
assistance, job training, food stamps and
public housing on passing a drug test.117
The disease model of addiction, in contrast to the
moral model, acknowledged biology and
genetics as significant contributors to addiction,
drawing on advances in genetics and brain
research. 1 This approach has contributed to the
concern that viewing addiction as a disease
might:
• Release the individual from personal
responsibility and the need for self-
control,119 and
• Engender feelings of hopelessness with
regard to effective treatment and the
possibility of recovery.120
These concerns, however, rarely are raised in
relation to other health problems and appear, at
least in part, to be reflective of the moral model
of addiction.
Evolving Approaches to Addressing
Addiction
America's approach to addressing substance use
and addiction has been filled with contradiction.
For example, at the turn of the 20th century,
cigarette smoking was frowned upon.121 Thanks
to effective marketing by the tobacco industry,
that view was replaced by one of tobacco use as
glamorous and even healthful,122 only to be
supplanted in the mid- 1 960s by a growing
understanding that cigarette smoking is a
significant contributor to poor health and
disease.123
Physicians prescribed marijuana and cocaine for
a variety of ailments in the late part of the 1 9th
century only to scale back in the first decades of
the 20th century in response to increasing
recognition of the adverse effects of these drugs
and increasing regulatory restrictions on their
use; today, there is a return to attempting to
frame marijuana as medicine.124 Similarly,
opium was used in the early part of the last
century to treat diarrhea, dysentery and
coughs.125 In response to the proliferation of
marijuana, hallucinogen, cocaine and heroin use
in the late 1960s and early 1970s-and their
association with political protest, crime and
-26-
addiction— and to the emerging "crack epidemic"
in the late 1980s, substance use and addiction
increasingly were criminalized.126 This trend
toward criminalization was reflected in federal
and state laws such as New York's Rockefeller
Drug Laws which created mandatory minimum
sentences of 15 years to life for possession of
four ounces of narcotics (about the same as a
sentence for second-degree murder).127 Later,
prescription opioid medications were heavily
marketed for pain which led to increased
negative consequences associated with their use
and renewed calls for increased legal
restrictions.128 (See Text Box on page 28.)
The latter half of the 20th century has seen more
systematic and consistent progress in how
addiction is perceived in the medical field. In
1956, the American Medical Association
(AMA) declared that alcoholism is an illness and
that it can and should be treated within the
medical profession;130 in 1967, the AMA
elaborated on this position in a manual for
physicians declaring that alcoholism is
characterized by a distinct pattern of symptoms,
chronicity, progression, and by a tendency
toward relapse and that it should be treated by
physicians.131 The U.S. Comprehensive Alcohol
Abuse and Alcoholism Prevention, Treatment,
and Rehabilitation Act of 1970 recognized
alcoholism as "an illness requiring treatment and
rehabilitation."132
Alcoholism must be regarded as within the
purview of medical practice. The Council on
Mental Health, its Committee on Alcoholism, and
the profession in general recognizes this syndrome
of alcoholism as illness which justifiably should
have the attention of 'physicians. ,133
—American Medical Association
Reports of Officers
Report of the Board of Trustees, 1956
In 1979, the AMA Council on Scientific Affairs
published Guidelines for Physician Involvement
in the Care of Substance-Abusing Patients
which put the weight of policy behind the
declaration that physicians are responsible for
addressing alcohol and other drug use in their
patients by engaging in diagnosis and referral (at
a minimum) and preferably interventions that
would ready the patient for treatment or actually
providing treatment and follow-up care; the
guidelines also specify the actions and
knowledge required for each level of physician
involvement.134 In 1989, a third of a century
after declaring that alcoholism is a disease, the
AMA adopted a policy declaring addiction
involving other drugs-including nicotine-to be
a disease.135
Addiction involving alcohol and other drugs first
was viewed by the field of psychiatry as a
symptom of an underlying personality disorder
in 1952; 136 in 1980, addiction involving nicotine,
alcohol and other drugs was described by the
American Psychiatric Association (APA) f as an
independent disorder-a substance use disorder
for which the clinician was instructed to specify
the substance involved in the addiction.137
From the mid- 1 990s through the present day
there has been a growing backlash against a
punitive approach to individuals with
addiction,138 concomitant with the growth in
scientific understanding of the brain processes
underlying addiction and the development of
evidence-based pharmaceutical and psychosocial
therapies to treat it.139 Yet it was not until the
late 1 990s that addiction began to gain broader
recognition as a brain disease.140
The history of addiction as a brain disease looks
a lot like the history of atoms or germs, insofar
as these were all older and controversial ideas
for which scientific confirmation later became
available.™
-David T. Courtwright, PhD
Professor, Department of History
University of North Florida
By the American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorder
(DSM), first edition. (See page 31 for a description
oftheDSM.)
1 In the DSM-III.
-27-
Select Examples of Shifting Perceptions
of Harms and Benefits of Addictive Substances in the U.S.
Tobacco. Cigarette smoking generally was frowned upon at the turn of the 20th century.141 However, highly
effective marketing campaigns conducted during the early and mid-20th century by the major tobacco companies
tremendously enhanced the appeal of smoking for men and women alike. The image of the cigarette smoker
projected by such campaigns— and by the entertainment media— was that of glamour, sophistication and even fitness.
Some medical professionals even signed on to the health message; tobacco advertisements featured physicians and
some appeared in medical journals. 142 In 1950, a landmark study linking smoking to lung cancer was published in
the prestigious Journal of the American Medical Association. 143 Over the next decade, more than 7,000 articles were
published linking smoking with lung cancer and other life -threatening diseases.1 In 1964, the first U.S. Surgeon
General's Report on Smoking and Health was published, concluding that smoking was hazardous to health and that
immediate action was warranted.145 It spurred a major, highly successful public health effort to reduce smoking and
other tobacco use. The truth about the dangers of smoking and the health consequences of second-hand smoke,
finally reached the public through unmistakable health evidence and powerful anti-tobacco health and legal
campaigns. Perceptions of smoking (and smokers) largely turned negative, public policy shifted toward widespread
bans and restrictions on smoking, and smoking rates have declined significantly.
Alcohol. The duality of alcohol— as a staple for celebrations, religious rituals or relaxing with family and friends, and
on the other hand as an underlying driver of crime, poverty, family dysfunction and illness-has a very long history.
Alcohol was considered in early America to be helpful for curing ailments, natural and healthy when used in
moderation, as an important source of nutrients and as a healthier alternative to water which often was
contaminated.146 The 19th and early 20th centuries saw a change in attitudes wherein excessive alcohol use was seen
as an impediment to worker productivity and as a contributing factor to problems such as domestic violence, poverty
and crime.147 The initial push for moderation in alcohol use (temperance) soon became a push for prohibition.148
Once the futility of prohibition became apparent and the law ultimately repealed, alcohol has been both extolled
through ubiquitous marketing and condemned for its tremendous societal and health-related costs. Conflicting views
on the dangers versus benefits of alcohol use persist with a growing list of scientific findings that the health and
social risks of excessive alcohol use and dangers of underage drinking outweigh any ostensible health benefits of
non-excessive drinking.
Marijuana. In colonial America, marijuana was a major commercial crop alongside tobacco and was grown for its
fiber much like cotton. In the 1920s, the recreational use of marijuana began to catch on, particularly among
entertainers. Marijuana use at this time was not illegal and was not considered a social threat. Between the mid- 19th
and 20th centuries, marijuana was even prescribed for various medical conditions including labor pains, nausea and
rheumatism. In the 1950s, marijuana use became increasingly popular and, in the 1960s, it became a symbol of
rebellion against authority. In the Controlled Substances Act of 1970, the federal government classified marijuana
along with heroin and LSD as a Schedule I drug-having the highest abuse potential and no accepted medical use-
formalizing its illegality and highlighting its potential for addiction. The 1980s and early 1990s saw the passage of
strict laws and mandatory sentences for possession of marijuana as well as the development of stronger strains of the
drug.149 In recent years, a growing number of states have enacted laws bypassing the established process of bringing
drugs to market in the U.S. which assures safety and efficacy and permitting the use of marijuana as "medicine."150
Opioids. The prescribing and dispensing of opioids by physicians and pharmacists were the major causes of the
increase in narcotic use (and addiction) that occurred in the 19th century.151 Opium and morphine were believed to
cure a variety of health conditions.152 At the turn of the 20th century, the Bayer Pharmaceutical Company promoted
heroin as "the sedative for coughs."153 At this time, there was some concern about the "moral degradation" caused by
opioid use, but drug users were not subject to legal sanctions.154 Increased concern about the spread of opioid
addiction prompted the passage of several Acts restricting the use and distribution of narcotics and making their non-
medical use illegal.155 Since that time, perceptions of narcotic/opioid use diverged dramatically, with prescription
opioids marketed as beneficial and illegal opioids seen as a scourge. In the late 1990s, the growth in the use of
prescribed pain relievers, tranquilizers and stimulants resulted in a widespread epidemic of prescription drug misuse
and addiction among people of all ages, which now pose an even larger addiction problem than their illegal
counterparts.156 In response, efforts to control this misuse have led, in some cases, to the under-treatment of pain.157
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Defining the Terms
Part of the problem in understanding the nature
of addiction is the lack of precision and
uniformity in the terms used to describe it and
distinguish it from substance use that threatens
health and safety but is not addiction.158 Various
terms such as experimentation, use, misuse,
risky use, hazardous use, excessive use, abuse,
dependence and addiction can be found in the
research literature and in popular parlance.
There are no standard connotations in use with
regard to the severity of the behavior, the
consequences of the behavior or the ability of
the individual to stop the behavior. Nor is there
recognition that the severity and consequences
of different levels of use vary considerably by
substance and with the age, gender and health
status of the user.
Further confusion can be found in the misuse of
the word "treatment" which historically has been
used to refer to a host of interventions including
detoxification, clinical treatment and
professionally-administered disease
management, social and mutual support and
other auxiliary services.* 159 Rarely has the term
treatment been reserved for those interventions
that are based in the clinical and scientific
evidence, as it is for the treatment of other
diseases.
As with other diseases, precise definitions are
essential to be able to stage the disease and
develop effective interventions and treatments.
The Continuum of Substance Use
Substance use includes smoking or otherwise
ingesting tobacco products, drinking alcohol or
Detoxification services are not considered
components of addiction treatment; rather, they are
precursors to treatment designed to manage acute
states of intoxication or withdrawal. Social and
mutual support and other auxiliary services can be
critical in supporting a patient through treatment and
helping over the long term to sustain advances
achieved through clinical treatment and to avoid
relapse.
using other addictive substances. The health
consequences of use of these substances increase
with frequency and quantity of use.160 The
continuum of use ranges from no use on one
end, to use that does not involve negative
consequences, to risky use-a public health
problem, to addiction-a medical problem.
Risky Substance Use: A Public Health
Problem. Risky substance use is defined, for
the purposes of this report, as the use of tobacco,
alcohol or other drugs in a way that can increase
the probability of harm to the user or to others
but does not meet clinical criteria for addiction*
More specifically, it includes the following
(sometimes-overlapping) categories:
• Use of any addictive substance by people
under the age of 21, for whom there is no
known safe level of use.§
1 Regardless of the legal status of the substance.
* The term risky use was chosen to reflect a range of
health and social risks inherent in the use of these
substances and to underscore the fact that significant
hazards can result from such use even in the absence
of clinical addiction. See Chapter III for a complete
account of the health and social consequences of each
of the following types of substance use that accounts
for their designation as risky substance use behaviors.
§ Age 21 was selected because of the cultural marker
of adulthood in the U.S., including the minimum
legal drinking age, although research documents the
continued development of the brain (and consequent
vulnerability to the effects of addictive substances)
into the mid-twenties.
The notion of critical periods, so integral to the
development of language or musical skills, is
relevant to the development of addiction as
well. It is clear from my work in addiction
medicine that use of addictive substances is
like a traumatic brain injury to a young person.
Any use by young people before brain
development is complete equals risky use.161
-Mark S. Gold, MD
University of Florida College of Medicine and
McKnight Brain Institute
Departments of Psychiatry, Neuroscience,
Anesthesiology, Community Health &
Family Medicine
Chairman, Department of Psychiatry
-29-
• Use of any addictive substance by pregnant
women, for whom there is no known safe
level of use.
• Use of any tobacco product; there is no
known safe level of use of tobacco products.
• Alcohol use in excess of the established
dietary guidelines for safe alcohol use of no
more than one drink per day for women and
two drinks per day for men, as described by
the U.S. Departments of Agriculture
(USDA) Dietary Guidelines.* 162 This
includes the non-mutually exclusive
categories of binge drinking,1 heavy
drinking* and heavy binge drinking.5
• Misuse (non-medical use) of controlled
prescription drugs and over-the-counter
medications**-i.e., using them for purposes
The guidelines also stipulate no alcohol
consumption for: (1) persons under the age of 21; (2)
pregnant women; (3) individuals who cannot restrict
their drinking to moderate levels; (4) individuals
taking prescription or over-the-counter medications
that can interact with alcohol; (5) individuals with
certain specific medical conditions (e.g., liver
disease, hypertriglyceridemia, pancreatitis); and (6)
individuals who plan to drive, operate machinery or
take part in other activities that require attention, skill
or coordination, or in situations where impaired
judgment could cause injury or death (e.g.,
swimming). Although drinking alcohol, as described
in (4) through (6) is considered risky substance use,
estimates of rates of risky substance use in this report
do not include these criteria since they are not
directly measured in the national surveys that were
analyzed for this study.
' Consuming five or more drinks on the same
occasion (within a few hours) on at least one day in
the past 30 days.
* When a woman consumes more than three drinks on
a given day or more than seven drinks during a given
week or when a man consumes more than four drinks
on a given day or more than 14 drinks during a given
week.
§ Binge drinking on at least five occasions in the past
30 days.
** In accordance with the federal Controlled
Substances Act of 1970 which created a system for
classifying illicit and prescription drugs according to
their medical value and their potential for misuse.
not prescribed or intended such as to get
high, feel stimulated or sedated; taking more
of the substance than prescribed or
recommended; or taking the substance too
often or for a longer period of time than was
prescribed or recommended. ft 163
• Use of non-prescribed federally controlled
(illegal/illicit drugs) drugs;K there is no
known safe level of use of these drugs.
Addiction: A Medical Disease. At the end of
the continuum of substance use are those who
meet clinical criteria for addiction. Yet even
among these individuals, there is tremendous
variation in the severity and course of the
disease. At the extreme end of the continuum is
TT For data analysis purposes, the national survey
examined for this report defines misuse of controlled
prescription medications more generally as "taking a
controlled prescription drug not prescribed for you or
taking it in a manner not prescribed for the
experience or feeling it causes." The misuse of over-
the-counter medications also constitutes risky use;
however, rates of risky substance use in this report do
not include the misuse of these medications since
they are not directly measured in the national surveys
that were analyzed for this study.
M Substances controlled (either through prohibited or
restricted use) by the federal Controlled Substances
Act of 1970 which created a system for classifying
illicit and prescription drugs according to their
medical value and their potential for misuse. In the
analyses presented in this report, illicit drugs include
marijuana/hashish, cocaine/crack, heroin,
hallucinogens, Ecstasy, methamphetamine and
inhalants. (See Chapter III.)
The public, and treatment sources alike, often are
confused as to the distinction among use, heavy
use and addictive disease. 164
-Stuart Gitlow, MD, MPH, MBA
Executive Director
Annenberg Physician Training Program in
Addictive Disease
Associate Clinical Professor
Mount Sinai School of Medicine
Acting President & AMA Delegate
American Society of Addiction Medicine
-30-
the most severe form of the illness: chronic
relapsing disease.
There are two leading sources of diagnostic
classifications for addiction (called substance
use disorders): The American Psychiatric
Association's Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV) and the World
Health Organization's International Statistical
Classification of Disease (ICD). Both reflect the
historical classification of addiction as a mental
disorder based on measures of its behavioral
symptoms rather than the current science
documenting the medical nature of the problem
as an underlying brain disease.166
Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV). The DSM-IV is the main
diagnostic reference of mental health
professionals in the United States and presents
three types of disorders that are drug specific:
(1) alcohol use disorders, (2) drug use disorders
and (3) nicotine dependence. Both alcohol and
drug use disorders involve two levels of
severity— abuse and dependence— while nicotine
only involves dependence. The criteria for
abuse are similar for alcohol and other drugs,
and the criteria for dependence are similar for all
three drug types.167
The DSM-IV defines substance abuse as "a
maladaptive pattern of substance use leading to
clinically significant impairment or distress."168
The term substance abuse, though widely used-
and often used beyond its clinical definition to
describe any kind of risky substance use-has
become controversial due to its negative, value-
laden and pejorative connotation.169
The term substance dependence is defined in the
DSM-IV as ". . .a cluster of cognitive, behavioral
and physiological symptoms indicating that the
individual continues use of the substance despite
significant substance-related problems."170
DSM-IV Criteria165
Substance Abuse
To be diagnosed with substance abuse, an individual
must exhibit one or more of the following four
symptoms within a 12-month period:*
• Recurrent use resulting in failure to fulfill major
role obligations at work, school or home;
• Recurrent use in physically hazardous
situations;
• Recurrent use resulting in legal problems; and
• Continued use despite persistent or recurrent
social or interpersonal problems.
Substance Dependence
To be diagnosed with substance dependence, an
individual must exhibit three or more of seven
symptoms within a 12-month period:
• Tolerance— the need for markedly increased
amounts of the substance to achieve intoxication
or the desired effect or a markedly diminished
effect with the continued use of the same
amount of the substance;
• Withdrawal-maladaptive behavioral change
with co-occurring physiological and cognitive
changes that occurs when use of a substance is
reduced or discontinued, or usage of a substance
to relieve or avoid withdrawal symptoms;
• Taking increasing amounts or using the
substance over a longer period than intended;
• A persistent desire or unsuccessful efforts to
reduce or control substance use;
• Spending a significant amount of time in
activities to obtain the drug, use it or recover
from use;
• Neglecting or giving up important social,
occupational or recreational activities because of
use; and
• Continuing use of the substance despite
knowledge of having a persistent or recurring
physical or psychological problem that is caused
or worsened by use.
* The symptoms must never have met criteria for
substance dependence for the class of substances
used.
-31-
Definitional Problems. The first two symptoms
of the DSM-IV's substance dependence
diagnosis-tolerance and withdrawal— reflect
physiological dependence on a substance as a
result of its regular use.171 There has been
considerable confusion about the difference
between physiological dependence on a
substance and addiction involving that
substance. This is further confused by the use of
the same term "dependence" to apply to both
conditions.
According to the DSM-IV diagnostic criteria,
tolerance and withdrawal symptoms neither are
necessary nor sufficient for a diagnosis of
substance dependence112 (e.g., an individual may
meet diagnostic criteria for addiction involving
cocaine or methamphetamine in the absence of
symptoms of tolerance and withdrawal).173
There also are cases where an individual is
physically dependent on a substance but does
not meet clinical criteria for addiction.174 This
occurs relatively frequently in relation to the use
of controlled prescription pain relievers.
Prolonged use of these medications may result in
physical symptoms, including tolerance and
withdrawal as a result of the body's adaptation
to taking the drug,175 but may not include the
loss of control and other behavioral symptoms
associated with addiction.176
Other symptoms of substance dependence also
can be observed in patients legitimately using
certain prescription medications.177 For
example, if a patient's pain is under- treated, he
or she may become preoccupied with finding a
pain medication or may take a pain medication
for a longer time than originally was
prescribed.178 Mischaracterizing this behavior as
addiction may result in further withholding of
legitimate pain treatment/ 179
Issues have been raised with regard to the
reliability and validity of the nicotine
Opioids.
f While the under-treatment of pain has been
acknowledged, there are emerging indications that
many physicians may now be overprescribing
addictive opioid medications for the treatment of
patients with non-malignant chronic pain.
dependence criteria as well: they have been
described as ambiguous, failing to address
important aspects of addiction involving nicotine
such as craving, too subjective and intertwined
with an individual's social context (e.g., with
regard to assessing the "costs" of continued use)
and limited in their ability to predict key
outcomes such as extent of tobacco use,
withdrawal severity and likelihood of future
cessation.180
Proposed Modifications to the DSM Diagnostic
Criteria. Partially because of these definitional
problems, work is under way to redefine and
reorganize the DSM's diagnostic criteria for
substance use disorders. These revisions are
proposed to be included in the upcoming DSM-
V version, which is estimated to be released in
May 20 13. 181 Among the proposed revisions is
the suggestion to replace the two categories of
substance abuse and substance dependence with
a single diagnostic category of substance use
and addictive disorders} 182 This modification
recognizes a broad category of addiction
including substance addiction and other
compulsive behaviors that reflect a common
neuropathology.183 Separate disorders would be
identified for each type of addictive substance or
behavior and for multiple addictive disorders.
The addictive disorder diagnosis would contain
1 1 criteria; meeting two or three criteria would
result in a diagnosis of "moderate" severity,
while meeting four or more criteria would result
in a diagnosis of "severe." The presence of
physical dependence (symptoms of tolerance or
withdrawal) also would be identified. § 184
1 Initially, the Substance-Related Disorders Work
Group for the revisions to the DSM considering
renaming this category "Addiction and Related
Disorders."
§ The proposed revised criteria clearly state that
tolerance and withdrawal are "not counted for those
taking medications under medical supervision such as
analgesics, antidepressants, anti-anxiety medications
or beta-blockers." This stipulation is designed to
prevent a patient who becomes physically dependent
on a prescription drug received during the course of
medical care from being diagnosed with addiction
(i.e., a substance use disorder).
-32-
One issue being raised in the proposed revisions
to the DSM is that of patients who are at
heightened risk of developing addiction in the
near future but do not now meet the diagnostic
criteria.185 One suggestion* is to add a severity
category of "mild" to the proposed "moderate"
and "severe" diagnosis categories. This
modification would help to identify risky
substance users and increase the chances that
they receive needed services to prevent their
risky use from progressing to addiction, while
reducing the risk of their receiving unnecessary
treatment which might accompany a more
severe diagnosis.186
International Statistical Classification of
Diseases (ICD). Like the DSM, the ICD does
not present a disease category of addiction;
rather, it presents mental health disorders that
are linked to psychoactive substance use
including nicotine, alcohol and other drugs.187
Like the DSM, the ICD offers two categories
related to addiction: in this case, harmful use
and dependence syndrome. Harmful use is
defined as "a pattern of psychoactive substance
use that is causing damage to health. The
damage may be physical (e.g., hepatitis
following injection of drugs) or mental (e.g.,
depressive episodes secondary to heavy alcohol
intake)." The ICD defines dependence
syndrome as "a cluster of behavioral, cognitive
and physiological phenomena that may develop
after repeated substance use. Typically, these
phenomena include a strong desire to take the
drug, impaired control over its use, persistent
use despite harmful consequences, a higher
priority given to drug use than to other activities
and obligations, increased tolerance and a
physical withdrawal reaction when drug use is
discontinued."188
The DSM vs. the ICD. While there is
considerable overlap between the diagnostic
definitions provided in the DSM and the ICD,
the ICD definitions connote more of a disease
state while the DSM definitions imply more of a
behavioral disorder. In addition, the ICD is used
Made by NAADAC, the Association for Addiction
Professionals.
more frequently internationally while the DSM
is used more frequently in the United States and
Canada.189 Access to the ICD codes is free to
the public via the Internet, whereas providers
must pay the American Psychiatric Association
for access to the DSM manual and codes, either
by purchasing the text version of the manual or
by paying to access the information online.190
The DSM is used more commonly than the ICD
in research studies, whereas the ICD has become
the primary tool used by health care facilities to
index health care data.191 The DSM criteria for
addiction involving nicotine are used less
frequently by researchers and clinicians than
criteria for addiction involving alcohol and other
drugs; 192
Like the DSM, the ICD currently is undergoing
revisions and there is hope that the parties
involved in the revisions to these classification
systems will take the opportunity to standardize
the language used to describe the full spectrum
of clinical addiction,193 with an increased focus
on the disease itself rather than different
disorders linked to specific substances.
It also is important to clarify that addiction is a
medical condition with significant behavioral
components.194 Recognizing that current
diagnostic classification systems like the DSM
and ICD do not sufficiently take into account the
shared underlying genetic and neurobiological
dimensions of addiction and various health
conditions— instead relying primarily on
subjective reports of symptoms of seemingly
unique and unitary conditions-the National
Institute of Mental Health (NIMH) has begun to
classify these conditions in a new way. The
Research Domain Criteria project (RDoC) aims
to develop a classification system based on
observable behavior and neurobiological
measures that underlie different manifestations
of addiction and related conditions which
currently are classified and addressed as distinct
conditions.195 Should this new system take hold,
1 Measures of addiction involving nicotine that are
considered to have greater predictive validity in terms
of outcomes include the Fagerstrom Test for Nicotine
Dependence (TTND) and Nicotine Dependence
Symptom Scale (NDSS).
-33-
it eventually may help practitioners diagnose
and address the disease of addiction and its
multiple manifestations in a more unified and
coherent manner in clinical practice.
Public Attitudes about Addiction
Public attitudes about a particular disease or
health condition and the people who suffer from
it historically have been linked to the public's
understanding of its causes and amenability to
treatment. This nation has a long history of
isolating and stigmatizing individuals with
health problems that were not well understood,
from tuberculosis to cancer, depression and
HIV-AIDS. Once scientific understanding of
the condition is solidified and the information
permeates public understanding, public attitudes
towards the condition and those who have it
often change. The availability of effective
treatments also can have a profound impact on
driving this change. Addiction is a prime
example of a disease where public attitudes have
yet to catch up with the science, although
attitudes are shifting.196
A 2005 online survey of 1,000 adults ages 20
and older about addiction involving alcohol
found that 63 percent of the general public see it
primarily as a personal or moral weakness ( 1 9
percent) or equally as a personal or moral
weakness and as a disease or health problem (44
percent); only 34 percent see it primarily as a
disease or health problem. In contrast, only 1 1
percent of individuals who are managing the
disease (i.e., in recovery) see it either primarily
as a personal or moral weakness (two percent) or
as both a personal or moral weakness and a
disease or health problem (nine percent); 81
percent see it primarily as a disease or health
problem. This survey also found that 43 percent
of physicians consider addiction involving
alcohol to be a personal or moral weakness (nine
percent see it primarily as a personal or moral
weakness and 34 percent see it equally as a
personal or moral weakness and as a disease or
health problem); 56 percent see it primarily as a
disease or health problem.197
A more recent survey of treatment providers in
the U.S. and the United Kingdom, published in
201 1, found that the belief that addiction is a
disease is stronger among those who provide
for-profit treatment while the belief that
addiction is a choice is stronger among providers
of public or not-for-profit treatment* 198— the
more common form of treatment in the United
States.199
Results from a nationally representative survey
conducted in 2008 found that 44 percent of the
public believes that people with addiction
involving alcohol could stop drinking if they
had enough willpower (73 percent of young
adults, age 18 to 24, hold this view). Fewer
Americans think the same is true for addiction
involving other drugs (38 percent of the public;
66 percent of young adults).200
A 2009 nationally representative survey of 1 ,000
adults ages 1 8 and older underscores the
tremendous stigma still associated with
addiction: individuals with addiction involving
alcohol or other drugs commonly were described
by respondents with words such as "sinner,"
"irresponsible," "selfish," "stupid," "loser,"
"undisciplined," "pathetic" and "weak."202
Differences also were found between providers who
were members of a group of addiction professionals,
had been treating addiction for longer, had stronger
spiritual beliefs, had a past addiction problem and
were older (tending to endorse the belief that
addiction is a disease) versus those who were not
members of a group of addiction professionals, had
less strong spiritual beliefs and were younger
(tending to endorse the belief that addiction is a
choice).
The average person in the U.S. views addiction
with a sense of hopelessness. They realize that
not all users of alcohol or other addictive drugs
will become addicted. They know that some
users will become addicted but that others will
not. This creates a belief that the addict can—
and should— use willpower to stop using.101
- J. Paul Molloy, JD
Chief Executive Officer
Oxford House
-34-
However, as a sign of increasing acceptance of
addiction as a disease, this same survey found
that the majority (78 percent) regard addiction
involving drugs other than nicotine or alcohol as
a chronic disease.203 Another 2009 nationally
representative survey of adults ages 1 8 and older
also found that the majority of the respondents
believe that addiction is a health condition that
requires ongoing attention and support (83
percent).204
Perceived Causes of Addiction
For decades, public misconceptions about the
origins of addiction have led to negative
attitudes and discrimination against those
afflicted with the disease and hindered progress
not only in understanding it, but also in
developing and providing effective treatments
for it.205 In 2008, CASA Columbia probed these
perspectives with a nationally representative
survey of American attitudes toward substance
use and addiction— the National Addiction Belief
and Attitude Survey (NABAS). Although public
attitudes increasingly appear to be reflective of
the science of addiction, people still often hold
conflicting views about the causes of addiction,
many of which are inconsistent with the growing
body of evidence.
CASA Columbia's NABAS found, for example,
that while many people understand that factors
such as genetics, family history, other health
problems and availability of addictive
substances play a role in the development of
addiction and that loss of control is a defining
characteristic of the disease, a significant
proportion of Americans cite "lack of will power
or self-control" as a primary causal factor.
Surprisingly, respondents who had a personal
experience with addiction— either that of a
family member or friend or their own— did not
differ much from the general public in these
perceptions of the key contributors to addiction.
Respondents also had different views on the
causes of addiction depending on the substance
involved.206
Tobacco/Nicotine. Despite the fact that
genetics account for up to 75 percent of the risk
for addiction involving nicotine,207 the NABAS
found that only one in four respondents (25.4
percent) cited "a predisposition to addiction, due
to genetics or family history" as a primary
causal factor when given a list of potential
causes of addiction involving tobacco/nicotine.
Respondents were most likely to cite an
"inability to resist peer pressure" (43.5 percent);
"easy availability of tobacco among youth"
(38.7 percent); "stress or anxiety about work,
family or other problems" (37.7 percent); and
"lack of willpower or self-control" (33.0
percent) as primary causal factors.208
(Figure 2. A)
Figure 2.A
Perceived Causes of Addiction
Involving Tobacco/Nicotine
Inability To Resist Peer Pressure
P
E
R
C
Easy Availability
I 38.7
Stress/Anxiety
| 37.7
E
N
Lack of Willpower/Self-Control
| 33.0
T
Predisposition/Genetics/
Family History
Source: CASA Columbia National Addiction Belief and Attitude
Survey (NABAS), 2008.
Note 1 : Respondents could choose two or three answers.
Note 2: Other research finds that genetics account for up to 75% of
the risk of nicotine dependence.
Alcohol. Public attitudes are more aligned with
the science regarding the role of genetics in
addiction involving alcohol. Genetics account
for 48 to 66 percent of the risk that someone
who drinks alcohol will become addicted209 and
nearly half (47.6 percent) of respondents to the
NABAS cite "a predisposition to addiction, due
to genetics or family history" as a primary
causal factor. Other perceived primary causes of
addiction involving alcohol include "stress or
anxiety about work, family or other problems"
(44.9 percent); "emotional disorders or mental
illness, such as depression or anxiety" (35.3
percent); "lack of willpower or self-control"
-35-
(29.7 percent); "easy availability of alcohol
among youth" (29.2 percent); and "inability
to resist peer pressure" (28.2 percent).210
(Figure 2.B)
Other Drugs. Although genetic factors
account for up to 78 percent of the risk for
developing addiction involving illegal or
controlled prescription drugs (depending on
the type of drug studied and the severity of
the addiction),211 only 27.5 percent of
NABAS respondents cited "a predisposition
to addiction, due to genetics or family
history" as a primary cause of addiction
involving prescription drugs. The most
commonly cited factor that may cause people
to become addicted to prescription drugs was
"emotional disorders or mental illness, such
as depression or anxiety" (40.8 percent).212
Co-occurring mental health disorders do
appear to play a significant role in the risk that
drug use will progress to addiction.213 Other
primary causes that were mentioned by
respondents to the NABAS include "stress or
anxiety about work, family or other
problems" (36.9 percent); "easy availability
of prescription medications among youth"
(36.7 percent); and a "lack of willpower or
self-control" (26.9 percent).214 (Figure 2.C)
Thirty percent cited "a predisposition to
addiction, due to genetics or family history"
as a primary cause of addiction involving
illegal drugs. The most commonly cited
factor that may cause people to become
addicted to illegal drugs was an "inability to
resist peer pressure" (41.9 percent). Other
factors that were mentioned as a primary
cause of addiction involving illicit drugs
include "easy availability of illegal drugs
among youth" (35.1 percent); "emotional
disorders or mental illness, such as depression or
anxiety" (34.8 percent); "stress or anxiety about
work, family or other problems" (29.9 percent);
and a "lack of willpower or self-control" (28.7
percent).215 (Figure 2.D)
Figure 2.B
Perceived Causes of Addiction
Involving Alcohol
Predisposition/Genetics/
Family History
Stress/Anxiety
Emotional Disorders/Mental Illness
Lack of Willpower/Self-Control
Easy Availability
Inability to Resist Peer Pressure
□ 47.6
3 44.9
35.3
| 29.7
| 29.2
28.2
Source: CASA Columbia National Addiction Belief and Attitude
Survey (NABAS), 2008.
Note 1 : Respondents could choose two or three answers.
Note 2: Other research finds that genetics account for 48% to 66%
of the risk that someone who drinks alcohol will develop an addiction
involving alcohol.
Figure 2.C
Perceived Causes of Addiction
Involving Controlled Prescription Drugs
Emotional Disorders/Mental Illness
| 40.8
P
Stress/Anxiety
| 36.9
E
R
Easy Availability
| 36.7
C
Predisposition/Genetics/
Family History
E
N
| 27.5
T
Lack of Willpower/Self-Control
| 26.9
Source: CASA Columbia National Addiction Belief and Attitude Survey
(NABAS), 2008.
Note 1 : Respondents could choose two or three answers.
Note 2: Other research finds that genetics account for up to 78% of the risk for
the development of addiction involving prescription and other drugs.
-36-
Figure 2.D
Perceived Causes of Addiction
Involving Illegal Drugs
Inability To Resist Peer Pressure
Easy Availability
Emotional Disorders/Mental Illness
Stress/ Anxiety
Predisposition/Genetics/
Family History
Lack of Willpower/Self-Control
Source: CASA Columbia National Addiction Belief and Attitude Survey
(NABAS), 2008.
Note 1 : Respondents could choose two or three answers.
Note 2: Other research finds that genetics account for up to 78% of the
risk for the development of addiction involving prescription and other
drugs.
The NABAS found little indication that
respondents attribute addiction primarily to an
"absence of religious faith or spiritual
grounding" or to "distorted moral values."216
-37-
-38-
Chapter III
Prevalence and Consequences
More than one in seven (15.9 percent, 40.3
million) people in the United States ages 12 and
older currently meet clinical criteria for
addiction* '--more than the share of the
population with cancer, diabetes or heart
disease. ' 2 An additional but unknown number
of people have the disease but are managing it
effectively and so do not meet these behavioral
criteria. 1 3 Another third of the population (31.7
percent, 80.4 million), while not addicted,
currently5 use one or more addictive substances
in ways that threaten their own health and safety
or the health and safety of others.4
Risky substance use and addiction are the largest
preventable and most costly public health and
medical problems in the U.S.5 Together they are
the leading causes of preventable death and
cause or contribute to more than 70 other
conditions requiring medical care.6 The
damaging effects of risky substance use and
addiction extend to a wide range of costly social
Defined as meeting criteria for past-month nicotine
dependence based on the Nicotine Dependence
Syndrome Scale (NDSS) and meeting diagnostic
criteria for past year alcohol and/or other drug abuse
or dependence (excluding nicotine) in accordance
with the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV). (The DSM refers to substance
abuse and substance dependence collectively as
substance use disorders. The criteria for nicotine
dependence in the NDSS parallel those of the DSM-
IV.) This estimate excludes the institutionalized
population, for which rates of addiction are higher.
f Includes coronary heart disease, angina pectoris,
heart attack or any other heart condition or disease,
excluding hypertension and stroke.
* There are no national data on the proportion of the
population that has been diagnosed with addiction
and is effectively managing the disease. Existing
national survey data indicate that 10 percent of adults
ages 1 8 and older report that they "once had a
problem with drugs or alcohol but no longer do"
(sometimes referred to as "sustained recovery"), but
it is not clear what proportion of this group ever was
diagnosed with addiction as distinguished from
"having a problem."
§ In the past 30 days.
-39-
consequences including crime, lost productivity,
child neglect and abuse, family dysfunction and
developmental disabilities.
Certain populations-including pregnant women,
adolescents and young adults and the elderly-
are more vulnerable to the damaging effects of
addictive substances. Other populations-
including those with co-occurring disorders,
members of the military exposed to combat and
those in the justice system— are more likely to
engage in risky use or have addiction.
Defining the Problem
Substance use can be understood as a continuum
ranging from having never smoked or used
alcohol or another drug at one end to having an
unmanaged chronic, relapsing diseasef at the
other. (Figure 3. A)
Figure 3. A
Continuum of Substance Use
Percent of Population Age 12+
by Level of Sustance Use*
12.7
25.2
14.5
31.7
Never
Used
No
Current
Use
Non-
Risky Use
Risky
Use
15.9
Addiction
* Includes tobacco, alcohol, illicit drugs and misuse of
controlled prescription drugs.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 2010.
Most people (87.3 percent) ages 12 and older in
the U.S. have used one or more addictive
Including any use of illicit drugs or the misuse of
controlled prescription drugs.
' This continuum focuses on substance use; the
category labeled addiction includes those individuals
whose substance use meets current clinical criteria
for this disease but does not include all individuals
with addiction. There are some individuals with the
disease of addiction who do not currently use any
addictive substances and others who currently may fit
into other use categories along the continuum.
substances at some point in their lives, and 62. 1
percent are current users.1 7 Those who have
never used an addictive substance, are not
current users5 or do not engage in risky
substance use are appropriate targets for public
health efforts aimed at preventing risky use and
addiction; however, these individuals are not the
focus of this report.
While this report focuses primarily on those with
the disease of addiction, it makes an important
distinction between addiction and risky use of
addictive substances:
• Those with the disease of addiction are
defined in this report as meeting the clinical
diagnostic criteria for past month nicotine
dependence or past year alcohol and/or other
drug abuse or dependence. Individuals who
meet diagnostic criteria for addiction are
targets for appropriate, evidence-based
clinical interventions by physicians and
other health professionals.
• Risky users of addictive substances are
defined in this report as those who currently
use tobacco products, exceed the U.S.
Department of Agriculture (USDA) Dietary
Guidelines for safe alcohol use,** 8
1 Current substance use among the entire U.S.
population ages 12 and older: 51.7 percent drink
alcohol; 27.6 percent use tobacco products; 7.5
percent use illicit drugs; and 2.8 percent misuse
controlled prescription drugs.
§ Having used the substance in the past 30 days.
The U.S. Department of Agriculture Dietary
Guidelines for safe alcohol use are no more than one
drink a day for women, no more than two drinks a
day for men and no alcohol consumption for:
(1) persons under the age of 21; (2) pregnant women;
(3) individuals who cannot restrict their drinking to
moderate levels; (4) individuals taking prescription or
over-the-counter medications that can interact with
alcohol; (5) individuals with certain specific medical
conditions (e.g., liver disease, hypertriglyceridemia,
pancreatitis); and (6) individuals who plan to drive,
operate machinery or take part in other activities that
require attention, skill or coordination or in situations
where impaired judgment could cause injury or death
(e.g., swimming). Due to data limitations, we were
unable to include categories 4-6 in our calculation of
risky drinkers.
-40-
misuse controlled prescription drugs, use
illicit drugs' 9 or engage in some
combination of these forms of substance use
but do not meet clinical diagnostic criteria
for addiction. Risky use can result in
devastating and costly health and social
consequences, including the disease of
addiction. Risky users are targets for public
health efforts aimed at reducing risky use
and of medical and other health professional
efforts to prevent risky use from progressing
to the disease of addiction.
To determine the scope of risky substance use
and addiction in the United States, CASA
Columbia examined national prevalence data1
for the total U.S. non- institutionalized
population ages 12 and older. For these
analyses, we examined current (past 30 day) use
of tobacco, alcohol and other drugs and the rate
of addiction involving these substances. Our
definition of addiction in this report is consistent
with the parameters used in the national survey
upon which our analyses are based-the National
Survey on Drug Use and Health (NSDUH)—
which categorizes respondents on the basis of
diagnostic criteria used in the Nicotine
Dependence Syndrome Scale (NDSS) for
nicotine dependence and in the DSM-IV for
alcohol and other drug abuse or dependence.
We also examined variations in the rates of risky
use and addiction by age, gender and race/
ethnicity. Because of the heightened
vulnerability to addictive substances while the
brain is still developing,5 10 we present data for
the following age groups: 12- to 17-year olds;
18- to 25-year olds; and those ages 26 and older.
While the NSDUH was used for these analyses
to present consistent data across age groups, it is
important to note that these data appear to
underestimate rates of current substance use
among adolescents by at least half" 11
Risky Substance Users
Approximately one-third (31.7 percent) of the
U.S. population ages 12 and older (80.4 million
people) currently' f use one or more addictive
substances in ways that threaten their own health
and safety-including increasing the risk of
addiction— or the health and safety of others, but
do not meet clinical criteria for addiction.
(Table 3.1) Nearly one-third (30.6 percent) of
risky users engage in risky use of two or more
substances. Alcohol is the substance most
frequently implicated in risky substance use,
followed by tobacco.12
For data analysis purposes, the national survey
examined for this report defines misuse of controlled
prescription medications more generally as "taking a
controlled prescription drug not prescribed for you or
taking it in a manner not prescribed for the
experience or feeling it causes." Fhe misuse of over-
the-counter medications also constitutes risky use;
however, rates of risky use in this report do not
include the misuse of these medications since they
are not measured directly in the national surveys that
were analyzed for this study.
' Substances controlled (either through prohibited or
restricted use) through the federal Controlled
Substances Act of 1970 which created a system for
classifying illicit and prescription drugs according to
their medical value and their potential for misuse. In
this analysis, illicit drugs include marijuana/hashish,
cocaine/crack, heroin, hallucinogens, Ecstasy,
methamphetamine and inhalants.
* Fhe most recent data available (2010) from the
Substance Abuse and Mental Health Association's
(SAMHSA) National Survey on Drug Use and
Health (NSDUH).
s See Chapter II.
** Because the NSDUH is conducted in the home
where an adult must be present, reported prevalence
rates for teens are significantly lower than reported
rates in school-based surveys where greater
anonymity is assured. For example, the Youth Risk
Behavior Survey's (YRBS) prevalence estimates for
12- to 17-year olds are 2.15 to 2.75 times as high as
those presented in the NSDUH.
ff In the past 30 days.
-41-
Table 3.1
Prevalence of Current Risky Use* of
Addictive Substances in
U.S. Population, Ages 12+, 2010
Percent of
Total
Population
Number
(in
Millions)
Total Risky Use
31.7
80.4
Tobacco With/Without
Other Substances
18.5
47.0
Tobacco Only
6.7
17.0
AlCOilOl W llw W ltflOUt
Winer oUDSiances
27.2
69.0
Alcohol Only
14.3
36.2
Illicit Drugs
WithAVithout
Other Substances
5.8
14.6
Illicit Drugs Only
0.6
1.6
Controlled Prescription
Drugs With/Without
Other Substances
2.1
5.4
Controlled Prescription
Drugs Only
0.5
1.1
Multiple Substances
9.7
24.6
Individuals included in the risky use category used
the substance in the past 30 days but do not meet
diagnostic criteria for addiction.
Source: CASA Columbia analysis of The National
Survey on Drug Use and Health (NSDUH), 2010.
Young adults, ages 18- to 25- years old, are
more likely to engage in risky substance use
than any other age group. (Figure 3. B) Men are
somewhat likelier to be risky substance users
than women: 33.9 percent (41.8 million) vs.
29.6 percent (38.6 million).13
Whites, Hispanics and blacks are likelier to
engage in risky substance use than persons of
other races/ethnicities.* 14 (Figure 3. C)
Figure 3.B
Current* Risky Substance Use
Among Individuals Ages 12+, 2010
Percent (Number in Millions)
31.7
(80.4 M)
40.9
(13.9 M)
J
14.3
(3.5 M)
r
32.3
(63.0 M)
Total
12 to 17
18 to 25
26+
* In the past 30 days.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 201 0.
Figure 3.C
Current* Risky Substance Use
Among Individuals Ages 12+ by Race/Ethnicity,
2010
Percent (Number in Millions)
White
Black
Hispanic
Other
* In the past 30 days.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 201 0.
The proportion of the population engaging in
risky substance use has remained stable over the
past decade; in 2002, 31.1 percent (73.1 million)
were risky substance users, as were 31.7 percent
(80.4 million) in 20 10. 15
"Other" races/ethnicities include American
Indian/ Alaska Native, Asian, Native Hawaiian/Other
Pacific Islander and multiracial non-Hispanic. These
races/ethnicities were combined for purposes of
analysis because there are too few respondents in
each category to calculate meaningful prevalence
data for each category separately. The "other
races/ethnicities" category is reported as a group vary between each racial/ethnic group in this
despite the fact that substance use prevalence rates category.
-42-
Risky Tobacco Use
In 2010, 18.5 percent of the U.S. population
ages 12 and older (47.0 million) reported current
risky use* of a tobacco product:
Risky tobacco use is slightly higher among
blacks than among whites and Hispanics; risky
use in these groups is higher than among persons
of other races/ethnicities.20 (Figure 3.E)
• Cigarettes: 14.0 percent (35.5
million);
• Cigars: 4.2 percent (10.6 million);
• Smokeless tobacco products: 3.0
percent (7.7 million); and
• Pipe tobacco: 0.7 percent (1.7
million).1 16
The majority (59.1 percent) of risky
tobacco users* also are risky users of
alcohol or other drugs. While not having
addiction involving nicotine, 18.2
percent of risky tobacco users have
addiction involving alcohol and/or other
drugs.17
Among all age groups, 18- to 25- year
olds have the highest rate of risky
tobacco use.18 (Figure 3. D)
Men are nearly twice as likely as women
to be risky tobacco users (24.1 percent,
29.7 million vs. 13.3 percent, 17.3
million).19
Figure 3.D
Current* Risky Tobacco Use
Among Individuals Ages 12+, 2010
Percent (Number in Millions)
30.4
(10.4 M)
18.5
(47.0 M)
0
9.0
(2.2 M)
17.6
(34.5 M)
Total
12 to 17
18 to 25
26+
* In the past 30 days.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 201 0.
Figure 3.E
Current* Risky Tobacco Use
Among Individuals Ages 12+ by Race/Ethnicity,
2010
Percent (Number in Millions)
18.7
(31.8 M)
20.5
(6.2 M)
18.2
(6.7 M)
13.8
(2.3 M)
White
Black
Hispanic
Other
* In the past 30 days.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 201 0.
Used a tobacco product in the past 30 days but do
not meet criteria for addiction involving nicotine
(i.e., nicotine dependence, as defined by the NDSS).
' These percentages represent the proportion of the
U.S. population ages 12 and older reporting risky use
of each type of tobacco product. These percentages
do not add up to the total of 18.5 percent because of
multiple substance use. Nationally representative
data on the use of water/ hookah pipes to smoke
tobacco are not available.
* Who do not have addiction involving nicotine.
-43-
Between 2002 and 2010, risky tobacco use in the
U.S. population ages 12 and older decreased
slightly, from 19.9 percent (46.8 million) in
2002 to 18.5 percent (47.0 million) in 2010.
Among adolescents (ages 12 to 17), the decrease
in risky tobacco use was more pronounced, from
12.0 percent in 2002 to 9.0 percent in 20 10.21
Risky Alcohol Use"
In 2010, 27.2 percent of the U.S. population
ages 12 and older (69.0 million) were current
risky drinkers:22
• 24.2 percent were age 21 and older who, on
average, exceeded the USDA guidelines for
safe alcohol use;
• 2.9 percent were under age 21 and drank
alcohol; and
• 0. 1 percent were adult pregnant women who
drank alcohol. ' 23
Within this population of risky drinkers:
• 69.6 percent1 were heavy drinkers-
consuming more than three drinks on any
day or more than seven drinks in any week
for women, and more than four drinks on
any day or more than 14 drinks in any week
for men;§
• 65. 1 percent** were current binge drinkers-
consuming five or more drinks on the same
occasion on at least one day in the past 30
days; and
• 14.7 percent' ' were current heavy binge
drinkers-binge drinking on at least five days
in the past 30 days.K 24
More than half (52.6 percent) of all current
drinkers are risky drinkers. Nearly half (46.4
percent) of risky drinkers§§ also are risky users
of tobacco or other drugs. While not having
addiction involving alcohol, 14.2 percent of
risky drinkers have addiction involving nicotine
and/or other drugs.25
As with tobacco, 18- to 25-year olds have the
highest rates of risky alcohol use.26 One in 10
adolescents ages 12 to 17 are risky drinkers.*** 27
(Figure 3.F)
Based on the USDA Guidelines for safe alcohol use
described on page 40. Excluded from the category of
risky drinkers are those who meet diagnostic criteria
for addiction involving alcohol in the past year.
Because the analyses were restricted
to the data available in the NSDUH, the component
of risky alcohol use that reflects the USDA
guidelines of no more than one drink a day for
women and two for men was measured by the item:
"On the days that you drank during the past 30 days,
how many drinks did you usually have?" As such, it
represents the average amount respondents drink on
days that they drink. If a woman drinks, on average,
more than one drink a day on days that she drinks or
if a man drinks, on average, more than two drinks a
day on days that he drinks, she or he would be
considered a risky drinker in this analysis.
' A portion of this category is included in the adult
risky drinker category above.
* 18.9 percent of the population (ages 12 and older),
48.0 million people.
§ Due to limitations of the NSDUH data set, weekly
consumption was computed as an average of monthly
drinking divided by 4.33, or 52 weeks / 12 months.
** 17.7 percent of the population, 44.9 million people.
^ 4.0 percent of the population, 10.1 million people.
** Rates of heavy, binge, and heavy binge drinkers
include only risky alcohol users who do not have
addiction involving alcohol.
§§ Who do not have addiction involving alcohol.
For individuals under age 2 1 , any alcohol use (in
the past 30 days) that does not meet criteria for
addiction is considered risky drinking.
-44-
Figure 3.F
Current* Risky Alcohol Use
Among Individuals Ages 12+, 2010
Percent (Number in Millions)
40.2
(13.7 M)
27.2
1
)
27.1
(52.9 M)
10.2
(2.5 M)
I
Total
12 to 17
1 8 to 25
26+
* In the past 30 days.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 2010.
Those ages 1 8 to 25 engage in binge and heavy
binge drinking at significantly higher rates than
those ages 26 and older.* 28 (Table 3.2)
More men than women engage in risky drinking
(28.3 percent, 34.9 million vs. 26.2 percent, 34.1
million). This difference becomes more
pronounced at higher levels of drinking: men
are almost twice as likely as women to be heavy
drinkers (23.8 percent vs. 14.3 percent) and
binge drinkers (23.6 percent vs. 12.1 percent),
and three times as likely to be heavy binge
drinkers (6.2 percent vs. 1.9 percent).29
Overall, whites are more likely to engage in
risky drinking compared to persons of other
races/ethnicities; however, Hispanics are slightly
Other national data indicate that while the
prevalence and intensity of binge drinking is highest
among individuals ages 18 to 34, adults ages 65 and
older who binge drink do so more frequently than any
other age group. Data regarding involvement in each
type of substance in this table and in subsequent
tables demonstrating demographic differences are
presented as any involvement with the substance
(with or without involvement with other substances)
because presenting risky use for each substance on its
own (without other substance involvement) results in
cell sizes that are too small to present reliable data.
As such, data on specific substances and multiple
substances shown in the tables are not mutually
exclusive.
more likely to engage in heavy and binge
drinking.30 (Table 3.3)
Table 3.2
Prevalence of Current Heavy, Binge and Heavy
Binge Drinking,* by Age, 2010
Percent (Number in Millions)
Heavy
Binge
Heavy
Drinking
Drinking
Binge
Drinking
Total Heavy, Binge,
and Heavy Binge
18.9
17.7
4.0
Drinking, Ages 12+
(48.0 M)
(44.9M)
(10.1M)
Age:
12- to 17-years old
5.2
5.0
0.8
18- to 25-years old
28.8
28.0
7.3
26+ years old
18.9
17.5
3.8
Were risky users of alcohol in the past 30 days but do not
meet diagnostic criteria for addiction involving alcohol.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 2010.
Table 3.3
Prevalence of Current Risky, Heavy, Binge and
Heavy Binge Drinking,* by Race/Ethnicity, 2010
Percent (Number in Millions)
Total Risky
Alcohol Use
Heavy Drinking
Binge Drinking
Heavy Binge
Drinking
White
28.5
(48.4M)
19.7
18.1
4.7
Black Hispanic Other
24.9
(7.5M)
16.0
15.6
2.2
27.0
(9.9M)
20.7
20.1
2.9
19.2
(3.2M)
12.6
11.9
1.9
Were risky users of alcohol in the past 30 days but do not
meet diagnostic criteria for addiction involving alcohol.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 2010.
Between 2002 and 2010, risky alcohol use in the
U.S. population ages 12 and older increased
slightly, from 26.4 percent (62.0 million) in
2002 to 27.2 percent (69.0 million) in 20 10.31
This increase was consistent across all forms of
risky drinking:
• Heavy drinking, from 18.2 percent to 18.9
percent;
-45-
• Binge drinking, from 16.9 percent to 17.7
percent; and
• Heavy binge drinking from 3.8 percent to
4.0 percent.32
Risky Illicit Drug Use
In 2010, 5.8 percent of the U.S. population ages
12 and older (14.6 million) reported current
risky use of illicit drugs,* primarily marijuana:33
• Marijuana/hashish: 5.6 percent (14.2
million);
• Cocaine/crack: 0.3 percent (0.8 million);
• Hallucinogens: 0.3 percent (0.8 million);
• Ecstasy: 0.2 percent (0.4 million); and
• Inhalants: 0.2 percent (0.5 million).* 34
Nearly all risky illicit drug users (81.6 percent)
also are risky users of tobacco, alcohol or
controlled prescription drugs. While not having
addiction involving illicit drugs, 40.3 percent
has addiction involving nicotine, alcohol and/or
controlled prescription drugs.35
Risky use of illicit drugs is highest among 1 8- to
25-year olds; adolescents ages 12 to 17 are more
likely to be risky users of illicit drugs than adults
ages 26 and older. (Figure 3.G) Risky
marijuana use follows the same pattern, with
13.6 percent (4.7 million) of 18- to 25-year olds,
4.9 percent (1.2 million) of 12 to 17-year-olds
and 4.0 percent of those ages 26 and older (7.9
million) engaging in risky use of marijuana/ 36
Used an illicit drug in the past 30 days but do not
have addiction involving illicit drugs. Data on the
risky use of methamphetamine and heroin cannot be
reported separately due to small sample size.
' These percentages do not add up to the total of 5.8
percent because of multiple substance use.
* Data on the risky use of other types of illicit drugs
cannot be reported separately by age, gender or
race/ethnicity due to small sample sizes.
Men are nearly twice as likely as women to be
risky users of illicit drugs (7.5 percent, 9.3
million vs. 4.1 percent, 5.3 million). Men also
are nearly twice as likely as women to be risky
marijuana users (7.1 percent, 8.8 million vs. 3.8
percent, 4.9 million).37
Blacks and whites are more likely to engage in
risky use of illicit drugs than Hispanics or
persons of other races/ethnicities.38 (Figure 3.H)
Figure 3.G
Current* Risky Illicit Drug Use
Among Individuals Ages 12+, 2010
Percent (Number in Millions)
14.2
(4.8 M)
5.8
(14.6 M)
5.8
(1.4 M)
4.3
(8.4 M)
Total
12 to 17
18 to 25
26+
* In the past 30 days.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 2010.
Figure 3.H
Current* Risky Illicit Drug Use
Among Individuals Ages 12+ by Race/Ethnicity,
2010
Percent (Number in Millions)
White
Black
Hispanic
Other
* In the past 30 days.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 201 0.
-46-
With regard to the risky use of marijuana
specifically, blacks are more likely to be risky
users (6.3 percent, 1.9 million), than whites (5.7
percent, 9.8 million), Hispanics (4.1 percent, 1.5
million) or persons of other races/ethnicities (3.3
percent, 0.6 million).39
The rate of risky use of illicit drugs has
increased slightly between 2002 (5.0 percent,
11.9 million) and 2010 (5.8 percent, 14.6
million) driven primarily by an increase in the
rate of risky use of marijuana (4.6 percent, 10.7
million in 2002 and 5.6 percent, 14.2 million in
20 10). 40
Risky Use of Controlled Prescription Drugs
In 2010, 2.1 percent of the U.S. population ages
12 and older (5.4 million) reported risky use of
controlled1 prescription drugs, with opioids
(pain relievers) the most frequently misused:41
• Opioids: 1.6 percent (3.9 million);
• Tranquilizers: 0.6 percent (1.5 million); and
• Stimulants: 0.3 percent (0.7 million). i 42
Of those who are risky userssS of controlled
prescription drugs, 65.8 percent (3.6 million)
also are risky users of tobacco, alcohol or illicit
drugs. While not having addiction involving
controlled prescription drugs, 43.6 percent of
risky users of these drugs have addiction
involving nicotine, alcohol and/or an illicit
drug.43
Risky use of controlled prescription drugs is
highest among 18- to 25-year olds; more 12- to
17-year olds report risky use of these drugs than
those ages 26 and older.44 (Figure 3.1)
Figure 3.1
Current* Risky Use of
Controlled Prescription Drugs
Among Individuals Ages 12+, 2010
Percent (Number in Millions)
4.3
(1.5 M)
2.1
(5.4 M)
2.3
(0.6 M
1.7
(3.4 M)
Total
12to 17
18 to 25
26+
* In the past 30 days.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 201 0.
This pattern is the same for the risky use of
opioids specifically: 2.0 percent of 12- to 17-
year olds, 3.2 percent of 18- to 25-year olds and
1.2 percent of individuals ages 26 and older are
risky users of opioids.**45
Men are slightly likelier to be risky users of
controlled prescription drugs (2.3 percent, 2.8
million) than women (2.0 percent, 2.6 million).
With regard to opioids, men also are more likely
to be risky users (1.8 percent, 2.2 million) than
women (1.3 percent, 1.7 million).46
Misused a controlled prescription drug in the past
30 days but do not have addiction involving
prescription drugs.
' Controlled by the U.S. Drug Enforcement
Administration because of their potential for misuse.
* Data on the risky use of sedatives cannot be
reported separately due to small sample size. These
percentages do not add up to the total of 2. 1 percent
because of multiple substance use.
§ Who do not have addiction involving prescription
drugs.
Data on the risky use of other classes of controlled
prescription drugs cannot be reported separately by
age, gender or race/ethnicity due to small sample
size.
-47-
Whites are more likely to be risky users of
controlled prescription drugs than persons of
other races/ethnicities.47 (Figure 3. J)
Figure 3. J
Current* Risky Use of
Controlled Prescription Drugs
Among Individuals Ages 12+ by Race/Ethnicity,
2010
Percent (Number in Millions)
2.3
(3.9 M)
1.7
(0.5 M)
2.1
(0.8 M)
_□
1.3
(0.2 M)
White
Black
Hispanic
Other
* In the past 30 days.
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 201 0.
Addictioiv
In 2010, a total of 15.9 percent of the U.S.
population ages 12 and older (40.3 million
people) met clinical diagnostic criteria for
addiction.1 50
Addiction involving nicotine and alcohol are the
most prevalent manifestations of addiction,
followed by addiction involving illicit drugs and
controlled prescription drugs.51 (Table 3.4)
However, with regard to the specific case of
opioids, Hispanics are slightly likelier than
whites (1.7 percent, 0.6 million vs. 1.6 percent,
2.8 million)* to misuse opioids.48
The rate of risky use of controlled prescription
drugs has remained relatively stable between
2002 (2.2 percent, 5.2 million) and 2010 (2.1
percent, 5.4 million); the rate of risky use of
opioids also has remained stable between 2002
(1.5 percent, 3.6 million) and 2010 (1.6 percent,
3.9 million).49
Data on risky opioid use among blacks (1.3 percent)
and persons of other races/ethnicities (1.0 percent)
cannot be reported as statistically significant due to
small sample sizes.
' The term "addiction" is used synonymously in this
report with the NDSS criteria for past 30 day nicotine
dependence, and the DSM-IV clinical diagnostic
criteria for past year alcohol and/or other drug abuse
and dependence (excluding nicotine) in accordance
with the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV). (The DSM refers to substance
abuse and substance dependence collectively as
substance use disorders. The diagnostic criteria for
nicotine dependence in the NDSS parallel those of
the DSM-IV). These are the criteria used by the
NSDUH to classify respondents as having a
substance use disorder. This definition is consistent
with the current move to combine abuse and
dependence into an overarching diagnosis of
addiction in the upcoming DSM-V. Available data
allow us to include in our prevalence estimates only
those who meet behavioral criteria in accordance
with the current diagnostic standards, meaning that
their disease is not effectively managed or has not
reached the point of behavioral symptoms.
Individuals who have the disease of addiction but do
not meet diagnostic criteria for past month (nicotine)
or past year (alcohol or other drug) addiction are not
included.
* This estimate excludes the institutionalized
population, for which rates of addiction are higher.
-48-
Table 3.4
Prevalence of Addiction in
U.S. Population, Ages 12+, 2010
Percent oi
XT 1_
Number
Total
s
Population
Millions)
Total AHHirtinn*
Nicotine With/ Without
9.0
22.9
Other Substances
Nicotine Only
7.1
18.0
Alcohol With/Without
7.1
18.0
Other Substances
Alcohol Only
5.0
12.6
Illicit Drugs
With/Without Other
2.2
5.6
Substances
Illicit Drugs Only
0.8
2.1
Controlled Prescription
Drugs With/Without
0.9
2.4
Other Substances
Controlled Prescription
Drugs Only
0.2
0.6
Multiple Substances
2.7
7.0
Based on past 30-day nicotine dependence, as defined
in the NDSS, and past-year alcohol and/or other drug
abuse or dependence, as defined in the DSM-IV.
Source: CASA Columbia analysis of The National
Survey on Drug Use and Health (NSDUH), 2010.
Those ages 1 8 to 25 have the highest rate of
addiction, including the highest rates involving
each type of substance, than any other age
group.53 (Figure 3.K; Table 3.5T)
Figure 3.K
Addiction Among Individuals Ages 12+, 2010
Percent (Number in Millions)
26.4
(9.0 m;
15.9
(40.3 M)
D
8.0
(2.0 M)
15.0
(29.3 M)
Total
12 to 17
18 to 25
26+
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 201 0.
Among those with addiction, 55.7 percent are
risky users of one or more other substances and
17.3 percent have addiction involving multiple
substances, including:
• 21.3 percent of those with addiction
involving nicotine;
• 30. 1 percent of those with addiction
involving alcohol;
• 75.2 percent of those with addiction
involving controlled prescription drugs; and
• 62. 1 percent of those with addiction
involving illicit drugs.52
Met diagnostic criteria for two or more of the
following: past 30-day nicotine dependence and/or
past year abuse/dependence involving alcohol, illicit
drugs and/or controlled prescription drugs.
1 Data regarding addiction involving each type of
substance in this table and in subsequent tables
demonstrating demographic differences are presented
as addiction involving the substance, with or without
addiction involving other substances, because
presenting addiction related to each substance on its
own (without other substance addiction) results in
cell sizes that are too small to present reliable data.
As such, data on specific substances and multiple
substances shown in the tables are not mutually
exclusive.
-49-
Table 3.5
Prevalence of Addiction, by Age Group, 2010
Percent (Number in Millions)
12- to
18- to
26+
17- years
old
25- years
old
years
old
Total Addiction,
8.0
26.4
15.0
Ages 12+
(2.0M)
(9.0M)
(29.3M)
Nicotine With/Without
Other Substance
Addiction
1.8
10.4
9.7
Alcohol With/Without
Other Substance
Addiction
4.6
15.8
5.9
Illicit Drugs
With/Without Other
Substance Addiction
4.1
6.5
1.2
Controlled Prescription
Drugs With/Without
Other Substance
Addiction**
(1.2)
(2.2)
(0.7)
Multiple Substances
2.7
6.7
2.1
Based on past 30-day nicotine dependence, as defined in
the NDSS, and past-year alcohol and/or other drug abuse
or dependence, as defined in the DSM-IV.
The rate of addiction involving controlled prescription
drugs is too low to assure statistical reliability of data by
age.
Source: CASA Columbia analysis of The National Survey
on Drug Use and Health (NSDUH), 2010.
It is important to note that 8.0 percent of
adolescents ages 12 to 17 have addiction.54 The
percent of adults who meet clinical criteria for
addiction declines with age.* The explanation
for this is not well understood and reliable
national data are not available on the proportion
of those with addiction for whom the disease is
chronic. It may be that some young people
receive treatment or otherwise successfully
manage the disease to the point where they no
longer meet diagnostic criteria for addiction as
they get older, while for some other young
people the disease may be fatal.
Men are more likely to have addiction than
women (19.1 percent, 23.6 million vs. 12.8
percent, 16.6 million). While rates of addiction
involving nicotine and controlled prescription
drugs are similar for both genders, rates of
addiction involving all other substances are
twice as high among men as women.55
(Table 3.6)
Table 3.6
Prevalence of Addiction," by Gender, 2010
Percent (Number in Millions)
Total Addiction,
Ages 12+
Nicotine With/Without Other
Substance Addiction
Alcohol With/Without Other
Substance Addiction
Illicit Drugs With/Without
Other Substance Addiction
Controlled Prescription Drugs
With/Without Other
Substance Addiction
Multiple Substances
Males Females
19.1
(23.6M)
9.9
9.5
2.9
(1.1)
3.5
12.8
(16.6M)
8.2
4.8
1.6
(0.8)
2.0
Based on past 30-day nicotine dependence, as
defined in the NDSS, and past-year alcohol and/or
other drug abuse or dependence, as defined in the
DSM-IV.
** The rate of addiction involving controlled
prescription drugs is too low to assure statistical
reliability of data by gender.
Source: CASA Columbia analysis of The National
Survey on Drug Use and Health (NSDUH), 2010.
23.7 percent (8.6 million) of adults ages 26-34;
16.8 percent (10.5 million) of adults ages 35-49;
13.8 percent (7.9 million) of adults ages 50-64; and
5.8 percent (2.3 million) of adults ages 65 and older.
-50-
Whites are more likely to have addiction than
individuals of other races/ethnicities. Rates of
addiction involving nicotine are highest among
whites, while rates of addiction involving
alcohol are highest among whites and Hispanics.
Rates of addiction involving illicit drugs are
highest among blacks.56 (Table 3.7)
Between 2002 and 20 1 0, the rate of addiction
declined from 17.6 percent (41.4 million) to 15.9
percent (40.3 million), driven primarily by the
decline in rates of addiction involving nicotine
(10.5 percent in 2002 to 9.0 percent in 2010).57
Special Populations
Certain populations-such as pregnant women,
the young and the elderly-are more vulnerable
to the damaging and addictive effects of
tobacco, alcohol and other drugs. Among
individuals with co-occurring disorders,
members of the military exposed to combat and
persons involved in the justice system, the
likelihood of risky use and addiction is
significantly higher than in the general
population.
Pregnant Women
In 2010, 16.2 percent of pregnant women were
risky users of tobacco, alcohol or other drugs
and 14.7 percent of pregnant women met clinical
criteria for addiction. ' Although pregnant
women are less likely to engage in risky
substance use or have addiction than non-
pregnant women,58 any substance use by
pregnant women is concerning because of the
risk of pregnancy complications, adverse health
consequences for the fetus and health and
behavioral consequences for children prenatally
exposed to addictive substances.59
Adolescents and Young Adults
Use of tobacco, alcohol and other drugs while
the brain is still developing increases the risk of
addiction. Because the brain continues to
Compared to 34.2 percent of non-pregnant women.
Compared to 16.2 percent of non-pregnant women.
Table 3.7
Prevalence of Addiction,* by Race/Ethnicity, 2010
Percent (Number in Millions)
White
Black
Hispanic
Other
Total Addiction,
Ages 12+
17.6
(29.9M)
13.4
(4.0M)
12.9
(4.7M)
9.9
(1.6M)
Nicotine With/
Without Other
Substance Addiction
10.9
6.9
4.2
4.9
Alcohol With/ Without
Other Substance
Addiction
7.4
5.8
7.6
5.0
Illicit Drugs With/
Without Other
Substance Addiction
1.9
3.5
2.9
1.6
Controlled Prescription
Drugs With/Without
Other Substance
Addiction
(1.0)
(0.6)
(1.0)
(0.7)
Multiple Substances
2.9
2.9
2.4
2.0
Based on past 30-day nicotine dependence, as defined in the
NDSS, and past-year alcohol and/or other drug abuse or dependence,
as defined in the DSM-IV.
The rate of addiction involving controlled prescription drugs is too
low to assure statistical reliability of data by race/ethnicity.
Source: CASA Columbia analysis of The National Survey on Drug
Use and Health (NSDUH), 2010.
develop into the mid-20s, the use of tobacco,
alcohol, controlled prescription drugs and illicit
drugs among 12- to 25-year olds is a significant
public health concern.60 Despite this, risky
substance use is high in this age group:
• About half (50.6 percent, 29.6 million) of
12- to 25-year olds have used a tobacco
product1 in their lifetime;
• Two-thirds (64.9 percent, 37.9 million) of
12- to 25-year olds have used alcohol in
their lifetime;
• Four in 10 (40.6 percent, 23.7 million) 12-
to 25-year olds have used an illicit drug in
their lifetime; and
• Approximately one-fifth (21.0 percent, 12.3
million) of 12- to 25 -year olds have misused
1 Includes cigarettes, cigars, pipes and smokeless
tobacco.
-51-
a controlled prescription drug in their
lifetime.61
Older Adults
The body's tolerance to addictive substances
declines with age,62 while the quantity and
frequency of prescription drug use typically
increases.63 These factors contribute to an
increased chance of risky substance use and
addiction. Also, as the "Boomer" generation
ages, seniors are reporting increasingly higher
rates of substance use and addiction, due to the
higher rates of substance use in this age cohort
compared with prior generations.64 Currently,
25.2 percent of the population ages 50 and older
engages in risky substance use and 10.6 percent
has addiction.* 65
Co-occurring Disorders
Addiction frequently co-occurs with other health
conditions.66 CASA Columbia's analysis of
national data indicates that in the past year, 57.5
percent of non-institutionalized individuals ages
18 and older f with addiction also have another
health condition:
• 31.9 percent have been told by a doctor that
they have a medical condition4 (not
including mental health disorders); and
• 39.4 percent meet clinical criteria for a
mental health disorder. § 67 (Figure 3.L)
The sample size is too low to provide any further
statistically reliable data on older adults ages 65 and
older.
' Data on mental health disorders among 12- to 17-
year olds are not available in the NSDUH.
* In the past year. Includes asthma, bronchitis,
cirrhosis of the liver, diabetes, heart disease,
hepatitis, high blood pressure, HIV/AIDs, lung
cancer, pancreatitis, pneumonia, STDs, sinusitis,
sleep apnea, stroke, tinnitus, tuberculosis and ulcer.
§ Includes those with a current or past year mental,
behavioral or emotional disorder (e.g., depression and
anxiety; excluding developmental disorders and
addiction) that meets DSM-IV criteria, or those with
a major depressive episode in the past year.
Figure 3.L
Rates of Mental Health Disorders Among
Individuals Ages 18+ with Addiction Involving
Specific Substances, 2010
Percent (Number in Millions)
71.2
(1.5 M)
39.4
(15.1 M)
57.2
(2.6 M)
44.5
(7.5 M)
37.0
(8.3 M)
Total
Controlled
Prescription
Drugs
llicit Drugs Alcohol
Nicotine
Source: CASA Columbia analysis of The National Survey on
Drug Use and Health (NSDUH), 201 0.
People with mental health disorders also are
more likely to be risky substance users and to
have addiction than those without a mental
health disorder. Among those ages 1 8 and older
who have a mental health disorder, 30.6
percent are risky substance users and 31.4
percent have addiction.68
In total, 6.6 percent of the non-institutionalized
U.S. population ages 18 and older (15.1 million)
meet clinical criteria for both addiction and a
mental health disorder. ' ' 69 Those with co-
occurring addiction and mental health disorders
also are likelier to have other co-occurring
chronic illnesses such as hypertension, asthma
and arthritis.
70
The rates of co-occurring mental health
disorders appear to be even higher among people
seeking treatment for addiction. One large-scale
study of adolescents and adults in addiction
treatment found that two-thirds of the patients
had co-occurring mental health disorders in the
year prior to treatment admission, with 18- to
25 -year olds most likely to have co-occurring
20.9 percent of adults (18 and older) in the U.S.
population meet clinical criteria for a mental health
disorder.
11 These rates are higher among institutionalized
persons; for example, CASA Columbia's 2010 study,
Behind Bars Update: Substance Abuse and America's
Prison Population, found that 24.4 percent of prison
and jail inmates have both addiction and a co-
occurring mental health disorder.
-52-
disorders. Attention deficit/hyperactivity
disorder and conduct disorder are the most
common co-occurring mental health disorders in
young patients being treated for addiction, and
anxiety and depression are the most common co-
occurring mental health disorders in older
patients; trauma-related disorders are common
across age groups.71
The link between mental illness and smoking is
particularly striking;72 individuals age 1 8 and
older with a mental illness involving serious
functional impairment' are nearly twice as likely
as those without such illnesses to have smoked
cigarettes in the past year (49.8 percent vs. 27.4
percent).73 Up to 60 percent of those with
depression, up to 70 percent of those with
bipolar disorder and up to 88 percent of those
with schizophrenia either are current or former
smokers.1 74 Those with clinical anxiety5 are
approximately twice as likely to be current
smokers (39.2 percent vs. 22.2 percent), have
smoked twice as many cigarettes in the past
month (139.5 cigarettes vs. 63.4 cigarettes) and
are more than twice as likely to have addiction
involving nicotine (21.2 percent vs. 8.4 percent)
as smokers without anxiety. Slightly more
than one-quarter of the population (26.9 percent)
has addiction, a mental health disorder or a
serious mental illness,' ' yet this group smokes
72.9 percent of all cigarettes.75
Ages 17 and younger.
' National data from 2010. A diagnosable mental,
behavioral or emotional disorder (excluding
developmental disorders and addiction involving
alcohol or drugs other than nicotine) of sufficient
duration to meet diagnostic criteria specified in the
DSM-IV that has resulted in serious functional
impairment, substantially interfering with or limiting
one or more major life activities. Comparable data
are not available for 12- to 17-year olds.
* These data are from a review of studies of clinical
and population-based samples.
§ Ages 12 and older.
Among smokers, those with anxiety smoked an
average of 355.5 cigarettes in the past month
compared to 286.2 cigarettes among smokers without
anxiety.
' r A mental, behavioral or emotional disorder that has
resulted in serious functional impairment which
substantially interferes with or limits one or more
major life activities.
Members of the Military Exposed to
Combat
Exposure to combat increases the risk of
addiction and co-occurring mental health
problems such as post-traumatic stress disorder
(PTSD), anxiety and depression. Addiction
involving alcohol is one of the most commonly-
reported disorders among Vietnam War
veterans,76 and co-occurring addiction and
mental health disorders are most prevalent
among veterans of the Vietnam era.77 Military
personnel and veterans of the more recent
conflicts in Afghanistan and Iraq also are at
increased risk of risky use and addiction as well
as co-occurring mental health disorders.78
A study of smoking among individuals who
were deployed or not deployed to Iraq and
Afghanistan found that those who were
deployed were more likely than those who were
not deployed to initiate smoking if they never
smoked before (2.3 percent vs. 1.3 percent), to
resume smoking if they had smoked in the past
(39.4 percent vs. 28.7 percent) and to have a
greater increase in their smoking rate if they
were smokers (57 percent vs. 44 percent). The
same study found that those who were deployed
and reported combat exposure were 1.6 times
more likely to initiate smoking (among never-
smokers) and 1.3 times more likely to resume
smoking (among past smokers) compared to
those who were not exposed to combat. The
likelihood of resumption of smoking post-
deployment was associated with length of
deployment.;t 79
One study using data from 2005 found that 40
percent of veterans from military operations in
Iraq and Afghanistan who sought Veterans
Administration (VA) health care screened
positive for risky alcohol use and 22 percent
screened positive for addiction involving
11 More than nine months and deploying multiple
times.
-53-
alcohol. Another study found that the
prevalence of risky alcohol use* was higher after
deployment to Iraq or Afghanistan compared to
pre-deployment.81 A study of soldiers who were
interviewed three to four months after returning
from deployment to Iraq found that 25 percent
engaged in risky alcohol use.§ Soldiers who had
higher rates of exposure to threats of injury or
death were more likely to engage in risky
alcohol use.82 A study of reserve/National
Guard and active duty personnel found that
reserve/National Guard personnel who were
deployed with combat exposure were 1.6 times
more likely than those deployed without combat
exposure to experience new-onset heavy weekly
drinking (8.8 percent vs. 5.6 percent) and 1.5
times more likely to report new-onset binge
drinking' ' (25.6 percent vs. 19.3 percent); active
duty personnel who were deployed to Iraq or
Afghanistan and reported combat exposure were
1.3 times more likely than those who were
deployed without combat exposure to report
new-onset binge drinking (26.6 percent vs. 22.0
percent).83 A study of National Guard Brigade
Combat Team soldiers deployed to Iraq from
March 2006 to July 2007 found that 13 percent
Based on scores on a version of the AUDIT
instrument (see Appendix H). Risky drinking was
defined as an AUDIT-C score of three or higher for
women and four or higher for men. Addiction was
defined as an AUDIT-C score of four or higher for
women and six or higher for men.
1 Of four U.S. combat infantry units (three Army
units and one Marine Corps unit).
* Measured with a two-question instrument asking,
"In the last year, have you ever drunk or used more
drugs than you meant to?" and "Have you felt you
wanted or needed to cut down on your drinking or
drug use in the last year?"
§ Answering yes either to: "In the past four weeks,
have you felt you wanted or needed to cut down on
your drinking?" or "In the past four weeks, have you
used alcohol more than you meant to?"
Men who consumed more than 14 drinks per week
and women who consumed more than seven drinks
per week.
n Those who reported drinking five or more drinks
(for men) or four or more drinks (for women) on at
least one day of the week or those who reported
"drinking five or more alcoholic beverages" on at
least one day or occasion during the past year.
met criteria for addiction involving alcohol
when they returned from deployment.*1 84
The risky use of prescription drugs also is
common among active duty personnel. One
study found that in 2008, 9.9 percent of service
members misused prescription drugs§§ (14.5
percent of Army, 9.1 percent of Navy, 10.2
percent of Marine Corps, 7.5 percent of Air
Force and 8.0 percent of Coast Guard service
members),85 a rate far higher than the 2.1 percent
who have misused controlled prescription drugs
in the general population.86
Soldiers exposed to combat who experience a
traumatic brain injury (TBI) are at particularly
high risk for the risky use of alcohol or other
drugs and for addiction. One study of service
members who were discharged from military
service found that those with mild TBI were 2.6
times more likely and those with moderate TBI
were 5.4 times more likely to be discharged for
addiction involving alcohol or for drug use
compared to the total discharge population.87
Another study of service members with blast-
induced mild-to-moderate injuries between 2004
and 2007 found that more than six percent of
service members with a mild TBI had post-
deployment addiction involving alcohol.88
Post-traumatic stress disorder (PTSD) also is
prevalent in the military population and co-
occurs at high rates with addiction. One study
of Iraq and Afghanistan veterans who were first-
time users of VA health care, found that among
those who met criteria for addiction involving
alcohol and/or other drugs, 63 to 76 percent also
met diagnostic criteria for PTSD.89
** Sixty-two percent of these soldiers met criteria
prior to deployment while 38 percent had a new
onset— that is, they met criteria post-deployment.
§§ In the past 30 days, misused prescription-type
amphetamines/ stimulants (including
methamphetamine), tranquilizers/muscle relaxers,
barbiturates/sedatives or opioids/pain relievers.
-54-
Involvement in the Justice System
Adolescents (ages 12 to 17) who have a lifetime
history of arrest are three times more likely to
engage in risky substance use or have addiction
compared with adolescents who have no arrest
record (60. 1 percent vs. 19.8 percent).90 They
are:
• Twice as likely to be risky substance users
(24.5 percent vs. 13.7 percent); and
• Five-and-a-half times as likely to have
addiction (35.6 percent vs. 6.2 percent).91
Previous research by CASA Columbia has found
that 78.4 percent of 10- to 17-year olds who are
in juvenile justice systems are substance-
involved;* 92 52.4 percent of juvenile or youthful
offenders incarcerated in state prisons and local
jails meet clinical criteria for addiction involving
alcohol or other drugs.93
Those ages 1 8 and older who have ever been
arrested are almost twice as likely to engage in
risky substance use or have addiction compared
to those with no arrest record (74.5 percent vs.
45.0 percent). More specifically, while they are
slightly more likely to be risky substance users
without having addiction (38.1 percent vs. 32.5
percent), they are three times as likely to meet
diagnostic criteria for addiction (36.4 percent vs.
12.5 percent).94
They were under the influence of alcohol or other
drugs while committing their crime, test positive for
drugs, are arrested for committing an alcohol or other
drug offense, admit having substance-related
problems or addiction or share some combination of
these characteristics.
Previous research by CASA Columbia found
that the majority (84.8 percent) of all inmates are
substance involved;1 64.5 percent of the inmate
population (nearly 1.5 million people) has
addiction involving alcohol or drugs other than
nicotine/
Consequences of Risky Substance
Use and Untreated Addiction
A broad range of health and social consequences
result from risky substance use and addiction,
including those discussed above for special
populations.96 Risky substance use and
addiction constitute the largest preventable
public health problems and the leading causes of
preventable death in the U.S.97 Of the nearly 2.5
million deaths in 2009, an estimated minimum
of 578,819 were attributable to tobacco, alcohol
or other drugs.5 98 (Table 3.8)
' They had a history of using illicit drugs regularly,
met clinical criteria for addiction, were under the
influence of alcohol or other drugs when they
committed their crime, had a history of alcohol
treatment, were incarcerated for an alcohol or other
drug law violation, committed their offense to get
money to buy drugs or had some combination of
these characteristics.
* Due to data limitations, the estimated rate of
addiction in the adult inmate population does not
include nicotine dependence. However, other
research suggests that the rate of tobacco use in the
justice population is higher than in the general
population. For example, in 2005, 37.8 percent of
state inmates and 38.6 percent of federal inmates
smoked in the month of their arrest. In contrast, the
current smoking rate in the general population at that
time was approximately 10 percentage points lower
(24.9 percent).
§ These numbers do not reflect the share of deaths
from a wide range of other health conditions
attributable to risky substance use and addiction.
-55-
Table 3.8
Deaths Attributable to Substance Use
Deaths/Year
Total Deaths Attributable to
578,819
Substance Use
Tobacco
443,000
Alcohol
98,334
Other drugs
37,485*
Based on data from 2009.
Sources: Tobacco— Centers for Disease Control and
Prevention (2008); Alcohol-CASA Columbia
analysis of the Alcohol and public health: Alcohol-
Related Disease Impact (ARDI) (2012); Other
Drugs— Centers for Disease Control and Prevention
(2010); Kochanek, K„ et al. (2011).
Four out of every 10 (39.6 percent) fatal traffic
crashes involve a driver who is under the
influence of alcohol or who tested positive for
other drugs.
Overdose deaths caused by controlled
prescription drugs and illicit drugs have
increased five-fold since 1990luuand now
surpass the total number of deaths caused by
traffic accidents.
101
Individuals with addiction are at increased risk
of potentially fatal diseases including cancer,102
heart disease103 and sexually-transmitted
diseases.104 More specifically, smoking
contributes to multiple types of cancer as well as
heart and respiratory disease.105 Alcohol
contributes to some of the leading causes of
death, including heart disease, cancer and stroke,
as well as to other serious illnesses such as
cirrhosis, hepatitis and pancreatitis.106 Injection
drug use contributes to HIV, hepatitis C and
hepatitis B.107 CASA Columbia's research
found that risky substance use and addiction
cause or contribute to more than 70 other
conditions requiring medical care, including
cancer, respiratory disease, cardiovascular
disease, pregnancy complications, HIV/AIDS,
cirrhosis, ulcers and trauma.108 (See Table 3.9)
The many negative consequences of our failure
to prevent risky substance use and treat
addiction extend beyond the individual to
family, friends, community and society.109
Risky substance use and untreated addiction
contribute to family dysfunction and financial
troubles, disrupted social relationships, unsafe
sexual practices, unplanned pregnancies, lost
work productivity, legal problems, poor
academic and career performance,
homelessness, property and violent crimes,
domestic violence, child abuse and neglect,
rapes and other sexual assaults and motor
vehicle crashes and fatalities.
no
Risky substance use and addiction adversely
affect the mental health of other family members
as well. Family members ages 1 9 and older are
at approximately twice the risk of having
addiction or clinical depression as those ages 1 9
and older in families without a member with
addiction, and they have higher health care
costs.111
Children and adolescents are particularly
vulnerable to the health consequences of
substance use. 1 12 Approximately 70 percent of
child welfare cases are caused or exacerbated by
parental risky use and addiction.113 Children
exposed to parental substance use are at
increased risk of emotional and behavioral
problems, conduct disorder, poor developmental
outcomes and risky substance use and addiction
in adolescence and adulthood.114 Children and
adolescents with family members who have
addiction are more likely to be diagnosed with a
number of medical conditions, including asthma,
depression, headaches, attention deficit/
hyperactivity disorder, trauma and addiction,
than children in families of similar demographic
characteristics who do not have a member with
addiction.115
Has a blood alcohol concentration of 0.08 or higher.
-56-
Table 3.9
Conditions Requiring Medical Care Attributable to Risky Use and Addiction
Tobacco-Related Conditions
Malignant neoplasm (Cancer)
Cardiovascular disease
Perinatal conditions
Lip, oral cavity, pharynx
Ischemic heart disease
Short gestation, low birth weight
Esophagus
Other heart disease
Respiratory distress syndrome
Stomach
Cerebrovascular disease
Other respiratory
Pancreas
Aortic aneurysm
Larynx
Other circulatory disease
Trachea/lung/bronchus
Respiratory diseases
Cervix uteri
Pneumonia, influenza
Kidney and renal pelvis
Bronchitis, emphysema
Urinary bladder
Chronic airway obstruction
Acute myeloid leukemia
Alcohol-Related Conditions
Acute pancreatitis
Laryngeal cancer
Acute Conditions
Alcohol abuse/Alcohol dependence syndrome
Liver cancer
Air-space transport
Alcohol cardiomyopathy
Liver cirrhosis unspecified
Alcohol poisoning
Alcohol polyneuropathy
Oropharyngeal cancer
Aspiration
Alcohol-induced chronic pancreatitis
Portal hypertension
Child maltreatment
Alcoholic gastritis
Prostate cancer (males only)
Drowning
Alcoholic liver disease
Psoriasis
Excessive blood alcohol level
Alcoholic myopathy
Spontaneous abortion (females only)
Fall injuries
Alcoholic psychosis
Stroke hemorrhagic
Fire injuries
Breast cancer (females only)
Stroke ischemic
Firearm injuries
Cholelithiases
Supraventricular cardiac dysrhythmia
Homicide
Chronic hepatitis
Hypothermia
Chronic pancreatitis
Prenatal, infant
Motor-vehicle non-traffic crashes
Degeneration of nervous system due to alcohol
Birth trauma
Motor-vehicle traffic crashes
Epilepsy
Digestive
Occupational and machine injuries
Esophageal cancer
Hemorrhage/hemolysis/endocrine/
jaundice/hematologic
Other road vehicle crashes
Esophageal varices
Hypoxia/asphyxia/respiratory
Poisoning (not alcohol)
Fetal alcohol syndrome
Infections
Suicide
Gastro esophageal hemorrhage
Integument/temperature regulation
Water transport accident
Hypertension
Length of gestation and fetal growth
Ischemic heart disease
Low birth weight/prematurity/
intrauterine growth restriction death
Other Drug-Related Conditions*
Drug-induced psychosis
HIV/AIDS
Other infectious diseases
Hepatitis
Inflammatory and toxic neuropathy
* Other-drug related conditions also may include kidney, liver and respiratory diseases as well as the accident, suicide and poisoning
categories listed above in the Alcohol-Related Conditions section.
Sources: Centers for Disease Control and Prevention. (2004b); Centers for Disease Control and Prevention. (2008a); Centers for Disease
Control and Prevention. (2008b); Merrill, J. & Fox, K. (1998); The National Center on Addiction and Substance Abuse (CASA) at
Columbia University. (1993); The National Center
on Addiction and Substance Abuse (CASA) at Columbia University. (1994).
-57-
Tobacco
Tobacco use is the leading preventable cause of
death and disability in the United States. An
estimated one in five, or 443,000, deaths each
year are attributable to cigarette smoking and
exposure to tobacco smoke;116 nearly 400,000
deaths per year are attributable to smoking-
related diseases.1 7 (Table 3.10)
Table 3.10
Average Tobacco- Attributable Deaths Due to
Smoking-Related Disease in the
United States, 2000-2004
Select Examples"
Average Deaths
Per Year
total
392,683
Cancers:
160,848
Lung, trachea, bronchus
125,522
Esophagus
8,592
Pancreas
6,683
Urinary bladder
4,983
Lip, oral cavity, pharynx
4,893
Kidney, renal pelvis
3,043
Larynx
3,009
Stomach
2,484
Acute myeloid leukemia
1,192
Cervix, uterus (females only)
447
Cardiovascular Diseases:
128,497
Ischemic heart disease
80,005
Other heart disease
21,004
Cerebrovascular disease
15,922
Aortic Aneurysm
8,419
Atherosclerosis
1,893
Other arterial disease
1,254
Respiratory Diseases:
392,683
Chronic airway obstruction
78,988
Bronchitis, emphysema
13,927
Pneumonia, influenza
10,423
These data do not reflect all tobacco-attributable deaths.
For example, deaths due to secondhand smoke and fire
burn are not included.
Source: Centers for Disease Control and Prevention
(2011).
Although the prevalence of tobacco use has
declined over the past two decades,121 mortality
rates have remained constant due to an increase
in population size, the identification of new
diseases linked to smoking and the fact that
cohorts that smoked heavily during their lifetime
are now reaching an age with the highest
incidence of smoking-attributable diseases.122
Over approximately the past four decades,* an
estimated 94,000 infant deaths have been linked
to prenatal exposure to smoking.123 Pregnant
women who smoke put their babies at increased
risk for a host of health problems including
placenta previa, ' stillbirth and sudden infant
death syndrome (SIDS).124 Smoking during
pregnancy increases the risk for preterm birth125
and pregnant smokers are 1.6 times more likely
to have a low birth weight baby than pregnant
nonsmokers (1 1.9 percent vs. 7.5 percent).126
Merely reducing the number of cigarettes
women smoke during pregnancy results in birth
weight gain; but even light smokers* are twice as
likely as nonsmokers to have low birth weight
infants. § 127 Low birth weight is a leading risk
factor for neonatal and infant mortality, can
result in restricted childhood development and
increases the risk of chronic disease,
developmental delays and cognitive
1 7 8
impairment.
The negative long-term health consequences for
children exposed to prenatal smoking include
increased risk for substance-related problems,
depression,129 attention deficit/hyperactivity
disorder, conduct disorders and childhood
obesity.130 The nicotine in tobacco products can
produce structural and chemical changes in the
developing adolescent brain and make young
people who smoke vulnerable to future addiction
and to certain forms of mental illness, including
panic attacks, panic disorder and other anxiety
disorders.131
Tobacco use contributes to approximately 30
percent of cancer and heart disease-related
deaths118 and numerous other health conditions
including respiratory illness and chronic kidney
disease.119 An estimated 8.6 million Americans
suffer from a serious smoking-related illness.120
* 1964 to 2004.
' The complete or partial obstruction of the cervical
opening by the placenta.
* Smoke less than half a pack a day.
§ In a study of low-income black women.
-58-
There also are serious health consequences for
nonsmokers exposed to environmental tobacco
smoke (ETS).132 Children exposed to ETS are at
increased risk of developing acute lower
respiratory infections, ear infections, asthma and
chronic respiratory symptoms,133 and of
becoming smokers and developing asthma in
adulthood.134 Exposure to ETS increases the
risk of lung, breast and other cancers, heart
disease, stroke and respiratory illnesses.135
Recently, the term "third-hand smoke" has been
developed to describe the invisible but toxic
gases and particles— including heavy metals,
carcinogens and radioactive materials— that form
a residue on smokers' hair, clothing and
household items and remain for weeks or
months after the second-hand smoke has
cleared.136 Like second-hand smoke, third-hand
smoke is a cancer risk.137
Alcohol
Alcohol use is the third leading cause of death in
the United States (after tobacco use and poor
diet/physical inactivity) and is responsible for
approximately 3.5 percent of all deaths.138 An
estimated 98,334 people die from alcohol-
related causes in the U.S. each year, including
chronic diseases (e.g., liver disease, cancer) and
acute causes (e.g., accidents, homicides).139
(Table 3.11)
Of the 13,555 substance-related traffic fatalities
in 2009, 10,185 involved drivers who were
alcohol impaired (BAC of .08 or higher).140
Young people are at greater risk of becoming a
victim of an alcohol-related traffic fatality
compared to older people.141 In 2009, 35
percent of 21- to 24-year old drivers involved in
fatal motor vehicle traffic crashes were under the
influence of alcohol, more than any other age
group.' 142
* Had a BAC of .08 or higher.
1 Compared to 19 percent of 15- to 20-year olds;
33 percent of 25- to 29-year olds; 29 percent of 30- to
34-year olds; 26 percent of 35- to 44-year olds; 22
percent of 45- to 54-year olds; 13 percent of 55- to
64-year olds; and 7 percent of 65- to 74-year olds.
Table 3.11
Average Alcohol-Attributable Deaths in the
United States 2001-2005,
Select Examples
Average Deaths
Per Year
Total
98,334
Chronic Causes;
Alcoholic liver disease
12,219
Stroke hemorrhagic
8,725
Liver cirrhosis, unspecified
7,055
Esophageal cancer
4,225
Alcohol denendence svndrome
3,857
Liver cancer
3,431
Breast cancer (females only)
1,835
Oropharyngeal cancer
1,528
Laryngeal cancer
1,460
Hypertension
1,480
Prostate cancer (males only)
1,025
Acute Causes:
Motor-vehicle traffic crashes
13,819
Homicide
7,787
Suicide
7,235
Fall injuries
5,532
Poisoning (not alcohol)
5,416
Fire injuries
1,158
Drowning
868
Alcohol poisoning
370
Hypothermia
269
Aspiration
204
Child maltreatment
168
Source: CASA Columbia analysis of the Alcohol and
public health: Alcohol-Related Disease Impact (ARDI).
In 2009, alcohol was reported in at least one-
quarter (24.3 percent) of substance-related
emergency department (ED) visits. 1 These
reports, however, significantly underestimate the
prevalence of alcohol-related emergency
department visits for two reasons: the data set
does not include visits linked to alcohol use in
combination with other drugs for persons under
the age of 2 1 , and many EDs do not screen for
* Measured in terms of patient visits, not individual
drug reports. The analyses of the Substance Abuse
and Mental Health Services Administration, Drug
Abuse Warning Network (DAWN) data assess the
number of drug mentions associated with a drug-
related emergency department visit; up to four drugs
plus alcohol may be recorded for each drug-related
visit.
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substance use because of state laws that exclude
alcohol and other drug-related injuries from
medical insurance coverage.* 143
Risky alcohol use and addiction involving
alcohol are associated with neurological
problems including dementia, stroke and
neuropathy;144 cardiovascular problems
including myocardial infarction,
cardiomyopathy, atrial fibrillation and
hypertension;145 psychiatric problems including
depression, anxiety and suicide;146 liver diseases
including hepatitis and cirrhosis;147 and
gastrointestinal problems including pancreatitis
and gastritis. 148 Other associated conditions
include increased risk of cancer of the liver,
breast, mouth, throat, esophagus and colon,149
and recent research suggests that risky alcohol
use may contribute to the physiological process
that causes cancer cells to metastasize.150
Heavy alcohol use during pregnancy is
associated with miscarriage and stillbirth and is
one of the primary causes of severe mental and
developmental delays in infants.151 Fetal alcohol
syndrome (FAS) is the leading known cause of
preventable mental retardation.152
Illicit Drugs
In 2008,' there were an estimated 16,044 deaths
attributed to the use of illicit drugs.153 Of the
13,555 substance-related traffic fatalities in
2009, 5,938 involved drivers impaired either by
illicit drugs alone (3,146 deaths) or illicit drugs
in combination with alcohol (2,792 deaths).154
In 2009, illicit drugs were involved in an
estimated 973,591 emergency department
visits;* accounting for 35.9 percent of substance-
related ED visits;155 cocaine, marijuana and
* In 25 states, Uniform Accident and Sickness Policy
Provision Laws (UPPL) exclude alcohol and other
drug-related injuries from medical insurance
coverage, creating a barrier to conducting screening
for risky substance use (see Chapters IV and X).
' Most recent available data that distinguishes
between illicit and controlled prescription drugs.
* Measured in terms of patient visits, not individual
drug reports.
heroin were the most frequently mentioned illicit
drugs.156
Injection drug use behavior— including sharing
needles and other injection paraphernalia—is
associated with the spread of HIV/AIDS.157 It is
estimated that more than one-third of all AIDS-
related deaths in the U.S. have occurred among
illicit drug users and their sexual partners.158
Morbidity (secondary illness) and mortality
(death) data related to illicit drug use may
represent the direct pathological effects or
medical toxicities from the drug (e.g., cocaine
producing seizures or strokes or inhalants
producing cardiac arrhythmias that can lead to
sudden cardiac deaths), but also the infections
transmitted via drug self-administration (e.g.,
intravenous or intramuscular self-
administration). 159
Marijuana use is associated with sexually
transmitted disease due to unsafe sexual
behaviors engaged in while under the influence
of the drug, bronchitis and lung cancer; cocaine
use is associated with pancreatitis; heroin use is
associated with hepatitis and tuberculosis;
hallucinogen use is associated with tinnitus and
sexually transmitted disease; and inhalant use is
associated with HIV/AIDS, sexually transmitted
disease, tuberculosis, bronchitis, asthma,
sinusitis and tinnitus.5 160
Illicit drug use also is linked to mental health
problems. Marijuana use is associated with the
onset of psychotic disorders, particularly in
individuals with an underlying vulnerability to
the illness;161 several longitudinal studies have
linked marijuana use with the subsequent onset
of schizophrenia, and case studies have linked
synthetic cannabinoids with psychosis.162
Marijuana and inhalant use are associated with
These health consequences are associated primarily
with long-term use of illicit drugs. The analyses
adjusted for potentially confounding factors such as
the duration of controlled prescription drug misuse,
alcohol use, tobacco use, daily cigarette smoking
history and demographic variables (age, gender,
race/ethnicity, educational attainment, health
insurance status and family income).
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anxiety and depression, and cocaine and heroin
use are associated with anxiety.* 163
Methamphetamine, cocaine and other stimulant
use (including the use of amphetamine-related
and other "designer drugs") are associated with
violent behavior, hallucinations, paranoia and
delusions which can be acute time-limited
symptoms or which can persist long after the
cessation of use.f 164 There is a range of
substance-induced disorders included in the
DSM-IV that reflect secondary mental health
effects of addictive substance use.165
Approximately 160,000 pregnancies in 2004
were associated with illicit drug use.166 Illicit
drug use during pregnancy increases the risk of
neurological and cognitive deficits in the fetus
and future behavior problems.167 Heavy
marijuana use has been associated with low birth
weight, premature delivery and complications in
delivery.168 Marijuana and cocaine exposure
have been linked to impaired attention, language
and learning skills, as well as to behavioral
problems.169
Infants exposed to prenatal illicit drug use are at
increased risk of low birth weight,170
developmental and educational problems and
future substance use and addiction.171
Controlled Prescription Drugs
In 2008/ there were an estimated 20,044
overdose deaths5 attributable to risky use of
controlled prescription drugs. The majority of
these deaths (73.8 percent or 14,800) were
attributable to the risky use of prescription
opioids.172 Overdose deaths from controlled
prescription drugs have increased significantly
over recent years and now surpass the number of
overdose deaths caused by illicit drugs.** 173
Enough prescription painkillers were prescribed
in 2010 to medicate every American adult
around-the-clock for a month. 174
—Centers for Disease Control and Prevention
In 2009, there were 224 deaths that involved
drivers impaired by controlled prescription drugs
(or an unknown combination of prescription
drugs, alcohol and other drugs).175 The risky use
of controlled prescription drugs was involved in
an estimated 1,079,683 emergency department
visits,' f accounting for 39.8 percent of all
substance-related emergency department visits
in the U.S. Among prescription drug-related ED
visits, 73.3 percent involved opioids, stimulants,
sedatives and barbiturates.1* 176
The risky use of prescription opioids can result
in a range of consequences from drowsiness and
constipation to depressed breathing, at high
doses. Even a large single dose of opioids can
lead to severe respiratory depression or death.177
One study found that individuals with addiction
involving opioids had significantly higher rates
of comorbid health conditions, including
hepatitis, pancreatitis and psychiatric illness than
those without addiction involving opioids.178
At high doses, risky use of prescription
stimulants can produce anxiety, paranoia,
seizures179 and serious cardiovascular
complications including stroke.180 Other
possible adverse effects include slowed growth
in children, allergic reactions, potentially fatal
interactions with other drugs§§ and sudden
death.181
* Adjusting for potentially confounding factors such
as those listed above.
' Producing what is described in the DSM-IV as a
Substance-Induced Mental Disorder.
* Most recent available data that distinguishes
between illicit and controlled prescription drugs.
§ Data on other causes of death (e.g., accidents) that
are attributable to the misuse of controlled
prescription drugs are not available.
Specifically, heroin and cocaine.
^ Measured in terms of patient visits, not individual
drug reports.
t+ The remaining prescription drug-related ED visits
involved antidepressants and antipsychotics (12.3
percent) or other types of prescription drugs (14.4
percent).
§§ Such as MAO inhibitors.
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Long-term risky use of benzodiazepines is
associated with cognitive impairment, other
adverse effects and a high risk of drug
interactions, addiction and withdrawal syndrome
that can be life threatening.182 Likewise, risky
use of barbiturates, such as butalbital and
phenobarbital, can lead to changes in alertness,
irritability and memory loss.183 If combined
with certain medications or alcohol, tranquilizers
and sedatives can slow both heart rate and
respiration, which can be fatal.184
Taking certain controlled prescription drugs
during pregnancy, such as alprazolam (Xanax)
or phenobarbital, may harm the developing
Chapter IV
Screening and Early Intervention
Nearly one-third (31.7 percent) of the U.S.
population (80.4 million people ages 12 and
older) engages in substance use that threatens
their own health or safety or the health and
safety of others, but does not meet clinical
diagnostic criteria for addiction. 1 Few of these
individuals, however, are routinely screened for
risky use of addictive substances or receive any
services designed to reduce such use such as
brief interventions.2 Of those who do receive
some form of screening, in most cases it
involves only one type of substance use-
tobacco or alcohol— which fails to identify risky
use of other substances or recognize that 30.6
percent of risky users who are not addicted
engage in risky use of more than one substance.3
In order to reduce risky use and its far-reaching
health and social consequences, which may
include the development of addiction, health
care practitioners must:4
• Understand the risk factors,* how these risks
vary across the lifespan and how risky use—
whether or not it progresses to addiction-
can have devastating outcomes for
individuals, families and communities;
• Educate patients, and their families if
relevant, about these risks and the adverse
consequences of risky use;
• Screen for risky use of addictive substances
and related problems using tools that have
been proven to be effective; and
• Provide brief intervention when appropriate.
Health care practitioners also should conduct
further assessment if the patient presents with
signs or symptoms of addiction and treat the
patient or provide referrals to specialty care if
needed, as discussed in Chapters V and VI.
See Chapter II.
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Screening and early intervention services should
be provided in regular health care settings, but
also can be highly successful when offered in
other venues to individuals at high risk,
including students, those in justice programs and
those in social service settings. To assure that
these health care services are provided, a range
of barriers must be addressed, including
insufficient training of health care and other
professionals and a lack of trained specialty
providers to which patients with addiction can
be referred for treatment; time constraints and
insufficient financial and workforce resources;
and screening tools that may fail to detect cases
of risky use of addictive substances.
The Need for Patient Education,
Screening and Intervention
throughout the Lifespan
For many health conditions, certain
developmental periods are associated with
increased risk of acquiring a disease.5
Addiction, in most cases, has its roots in
adolescence with the initiation of risky use of
addictive substances,6 but the onset of risky use
and addiction can occur at any point in the
lifespan. Each life phase presents unique
vulnerabilities that must be recognized, as well
as the basic risk factors (discussed in Chapter II)
that may be present at any time in life.
Childhood and Adolescence
Adolescence is the critical period for the onset
of substance use and its consequences,* 7 but
signs of risk sometimes can be observed much
earlier. In addition to the overall risks
associated with substance use, children and
adolescents with heightened risk of engaging in
substance use, of experiencing the adverse
consequences of risky use and of developing
addiction include:
• Those with certain genetic predispositions or
structural or functional brain characteristics
that make them more susceptible to
addictive substances;8
See Chapter II.
• Young children whose temperaments' are
more active, impatient, aggressive and non-
conforming than their peers,9
• Those with behavioral disorders including
oppositional defiant disorder' and conduct
disorder/ 10 those who engage in bullying5 11
and those who have sleep problems;** 12 and
• Children who are maltreated, abused or have
suffered other trauma.13
As children age, moving through elementary and
middle school-a period that coincides with first-
time exposure to cigarettes and other drugs— they
are presented with increasing academic and
social challenges and responsibilities that
increase their risk of trying addictive substances
and engaging in substance use.14
During adolescence and into early adulthood the
brain undergoes considerable developmental
changes, explaining why adolescence is such a
risky period for the onset of substance use and
addiction.15 Hormonal changes that occur
during adolescence also pose a biological risk
for substance use in this age group. The surge in
the female hormone estrogen and the male
hormone testosterone during puberty is
associated with risk taking and sensation
According to the American Academy of Child and
Adolescent Psychiatry, oppositional defiant disorder
refers to a pattern of disobedient, hostile and defiant
behavior directed toward authority figures. Common
behavioral symptoms include defiance, spitefulness,
negativity, hostility and verbal aggression.
* Conduct disorder is diagnosed in youth who exhibit
enormous difficulty following rules and behaving in a
socially-acceptable manner. These children may
bully others, start fights, show aggression toward
animals, steal or engage in sexually inappropriate
behavior.
§ Past-year participation in the following acts: (a) hit
and pushed or threatened another student, (b) called
another student mean names, (c) told another student
you will not like her/him unless she/he did what you
wanted, (d) made people not like another student, (e)
told lies or spread rumors about another student, (f)
not let another student be in your group of friends.
Mothers' reports of children and teens having
trouble sleeping and overtiredness.
-64-
seeking. The lack of fully developed decision-
making and impulse-control skills combined
with the hormonal changes of puberty
compromise an adolescent's ability to assess
risks and make them uniquely vulnerable to
substance use.16
Other psychological and social challenges faced
by adolescents— such as the struggle to develop a
sense of identity, feeling less satisfied with one's
appearance and experiencing peer pressure to
conform— contribute to the risk. 7
Young Adulthood
In recent years, researchers have begun to
recognize the developmental stage of young
adulthood— often referred to as emerging
adulthood-as a period of life that is strongly
associated with risky use.18 Young adults facing
heightened risk include:
• College students-* -while approximately
two-thirds of college students who engage in
substance use began to smoke, drink or use
other drugs in high school or earlier, the
culture on many college campuses permits
and promotes risky use rather than curtailing
it.19
• Young adults facing work-related stress or
instability in living arrangements, social
relations or academic or career choices.20
As marriage and parenthood have become
delayed, the phase of life devoted to
academics and career development has
stretched well into the twenties. Young
adults may turn to addictive substances to
relieve these forms of stress and self-
medicate their anxiety and emotional
troubles.21
Middle and Later Adulthood
Major life events and transitions increase the
chances that an individual will engage in risky
use of addictive substances.22 Adults may turn
to risky use when:
Much of the research conducted on young adults is
based on college student samples.
• Coping with the stresses of child rearing,
balancing a career with family and
managing a household;23
• Facing divorce, caring for an adult family
member or grandchildren or coping with the
death of a loved one;24
• Struggling with retirement, the loss of
independent living or financial problems;25
or,
• Coping with an illness, including increasing
physical ailments such as arthritis or other
forms of chronic pain.26
Middle aged and older adults who engage in
risky use may be even more vulnerable to the
health consequences of such use since physical
tolerance for alcohol and other drugs declines
with age: the ways in which addictive
substances are absorbed, distributed,
metabolized and eliminated in the body change
as people get older.27 With regard to alcohol,
several biological factors account for reduced
tolerance. The amount of lean body mass
(muscle and bone) and water in older adults'
bodies decreases as the amount of fat increases,
with less water to dilute the alcohol. Reduced
liver and kidney function slows down the
metabolism and the elimination of alcohol from
the body, including the brain. These factors
allow the effects of alcohol to take hold more
quickly and depress brain function to a greater
extent than in younger people, impairing
physical coordination and cognitive function.28
The increasing susceptibility to substance-
induced neurotoxicity with age is a growing
concern as the "Boomer" generation, a
population with higher rates of risky use, ages.29
The interaction of prescribed and other drugs
with alcohol also is of great concern for the
physical and mental health of middle and older
adults who are likelier than younger people to
use prescription and over-the-counter
medications.30
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Attending to Co-occurring
Conditions
Individuals who engage in risky use or who have
addiction frequently suffer from other co-
occurring health conditions.* 31 Therefore, any
attempt to identify risky use of addictive
substances, evaluate an individual's risk for
developing addiction or assess a substance
user's need for intervention or treatment must
involve identification of co-occurring conditions
and plans to address them. Being informed of a
patient's health conditions that might be caused
or exacerbated by substance use or that might
cause or exacerbate the patient's addiction will
help medical professionals determine
appropriate interventions and provide effective
care.32 Similarly, medical professionals treating
patients with medical conditions that frequently
co-occur with risky use and addiction- such as
hypertension, gastritis and injuries— should be
prompted to screen for risky use of addictive
substances that may cause or aggravate these
conditions.
• Steps patients can take to prevent risky use
of addictive substances and the onset of
addiction, e.g., by delaying initiation of
substance use, following guidelines for the
safe use of alcohol and of controlled
prescription medications, being vigilant for
signs and symptoms of risk and seeking
professional help at the first sign of trouble.
Screening1
Screening, a staple of public health practice that
dates back to the 1930s,34 serves to identify early
signs of risk for or evidence of a disease or other
health condition and distinguish between
individuals who require minimal intervention
and those who may need more extended
treatment.35 It is an effective method of
preventive care in many medical specialties, and
risky use of addictive substances is no
exception. Screening for risky use of addictive
substances is comparable to offering regularly
scheduled pap smears or colonoscopies to
identify cancer indicators.36
Patient Education and Motivation
Educating patients and motivating them to
reduce their risky use of addictive substances is
a critical component of preventive care.33 As
part of routine medical practice, medical and
other health professionals should educate their
patients (and parents of young patients) about:
• The adverse consequences of risky use and
the nature of addiction— that it is a disease
that can be prevented and treated
effectively;
• The risk factors for substance use, tailoring
the information to the patient's age, gender,
mental health history and other relevant
medical, social and demographic
characteristics;
• Times of increased risk for substance use,
such as adolescence, key life transitions
and stressful life experiences; and
See Chapter II.
' Despite the distinction between screening and
assessment tools, the term screening often is used to
subsume the concept of assessment or
interchangeably with the term in the clinical and
research literatures. Nevertheless, Chapter V
addresses assessments specifically. In addition,
while there is some overlap between screening or
assessment procedures used to identify risky use of
addictive substances and methods used to diagnose a
clinical addiction, a formal diagnosis of addiction is
based on the demonstration of specific symptoms
included in the most recent versions of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or
the International Statistical Classification of Diseases
(ICD). (See Chapter II.)
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It's like taking a blood pressure. You don't just
take the pressure of patients you suspect of
having high blood pressure. You take
everyone 's blood pressure. And, with public
health screening, you 're typically not shooting
for a diagnosis, but just an initial measure of a
patient's level of risk?*
—Dan Hungerford, DrPH
Epidemiologist
National Center for Injury
Prevention and Control
Centers for Disease Control and Prevention
Screening tools typically are brief and easy to
administer and are to be implemented with a
relatively broad population to identify
indications of risk involving smoking, drinking
or using other drugs. Screening tools typically
include written or oral questionnaires and, less
frequently, clinical and laboratory tests. (See
Appendix H for a description of commonly-used
screening instruments.)
An instrument that can be used to screen for
risky use of all addictive substances— rather than
separately for each substance-and that makes
appropriate distinctions for young people and by
gender has yet to be developed.
In recent years, attempts have been made to
develop and validate more simple screening
tools that can be used in primary care settings.
For example:
• A single-item measure of current tobacco
use* has been validated on adult populations
for use in research protocols37 but also can
be used clinically to determine if a patient is
a current smoker.
• The National Institute on Alcohol Abuse and
Alcoholism (NIAAA) recommends a single-
question screening test for unhealthy alcohol
Have you smoked one or more cigarettes in the past
month?
use ' to be asked of patients of all ages who
admit to sometimes drinking alcohol.39
• The NIAAA, in collaboration with the
American Academy of Pediatrics (AAP)
recently introduced a simple screening tool
for identifying early signs of risky alcohol
use in young people ages 9-18. The
screener begins with two simple questions
assessing the child's own alcohol use and
that of his or her friends. Depending on the
patient's age, positive responses to these
items would be followed by more in-depth
questions assessing the level of the patient's
risk and the provision of appropriate brief
interventions.40
• A recent study found that a single-question
screening test to identify other drug use in a
diverse sample of adult primary care patients
was effective in accurately identifying other
drug use and may be beneficial in helping
physicians identify potential medication
interactions and associated risks of
prescribing specific medications.41
Single-item screening tools can help narrow the
patient population that requires further
assessment for the identification of addiction.42
However, most instruments focus on specific
substances rather than the range of addictive
substances that pose a risk for addiction. The
National Institute on Drug Abuse (NIDA) has
begun to move in the direction of a more unified
look at risky use and addiction with the
development of a "quick screen" for use in
general medical settings. The instrument
actually contains four separate screens and asks
patients about the frequency of their past-year
use of each of the following types of substances:
(1) tobacco, (2) alcohol,5 (3) prescription drugs
1 How many times in the past year have you had 5 or
more drinks in a day (for men)/4 or more drinks in a
day (for women)?
* How many times in the past year have you used an
illegal drug or used a prescription medication for
nonmedical reasons?
§ With separate measures of risk for males and
females— the frequency of having five or more drinks
in a day for men and four or more drinks in a day for
women.
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(for nonmedical reasons) and (4) illicit drugs.
Response options for each, on a five-point scale,
range from never to daily or almost daily. Used
online, the screening tool tallies the responses to
generate a score indicating the patient's level of
risk for each type of substance and the
recommended level of intervention. It also
provides additional resources to help
practitioners intervene appropriately.43
Implementing screening and brief intervention
would be a revolution in 21st century medical
practice. It would help reduce billions of
dollars annually in lost productivity, injury and
social costs associated with risky behaviors. It
would also encourage those with chronic
conditions to get the treatment they need. But
medical practices are unlikely to take action
without pressure from others who would
benefit. The question is, when will society
demand this change?^
-John C. Higgins-Biddle, PhD
Assistant Professor (Retired)
Community Medicine and Health Care
University of Connecticut Health Center
Laboratory Tests
One approach to screening is to examine
laboratory values of urine, hair, blood, sweat,
saliva or carbon monoxide* to determine the
presence of nicotine,45 alcohol46 or other drugs.4
Laboratory tests also can be used to look for
biological symptoms of chronic substance use.48
For example, to assess heavy alcohol use,
doctors can look for elevated levels of the blood
proteins gamma-glutamyl transferase (GGT) or
carbohydrate-deficient transferrin (CDT). ' The
size of red blood cells also increases with
prolonged heavy alcohol use.49 The validity of
testing for these markers as a means of
identifying risky alcohol use is limited by the
fact that they are not necessarily unique to risky
drinkers.50 For instance, increased GGT also
* Carbon monoxide breathalyzer tests used to detect
smoking.
' Heavy drinkers are defined in this context as
individuals who consume four or more drinks per
day. CDT is less accurate at determining heavy
drinking in women and adolescent populations.
can be caused by nonalcoholic liver disease. At
the same time, looking for biological markers is
more objective than using a patient's self-
reports,51 as it is not subject to patients' or
examiners' biases.
Unlike tests for other diseases such as diabetes
and hypertension which can be diagnosed using
blood sugar or blood pressure measurements,
there is not a conclusive test that physicians can
conduct to determine with certainty the presence
of the disease of addiction.52 With few
exceptions,* laboratory tests for nicotine, alcohol
and other drugs generally inform health care
providers of whether patients recently5 have
been using these substances rather than being
indicators of chronic use or addiction.53
Individuals, groups and organizations may be
hesitant to agree to laboratory tests for substance
use for legal, financial or personal reasons.54
Widespread use of these tests is costly55 and, as
with any other biological testing, the possibility
1 A liver function test that indicates an elevated level
of GGT and a complete blood count that indicates
that the red blood cells have a greater than normal
mean corpuscular volume (MCV) are evidence of
chronic heavy alcohol use.
§ With regard to smoking, high levels of nicotine or
cotinine indicate active tobacco use or use of nicotine
replacement therapy (NRT); moderate concentrations
indicate a smoker who has not had tobacco or
nicotine for two to three weeks; lower levels may
indicate a non-smoker who has been exposed to
environmental tobacco smoke; and very low to non-
detectible concentrations are found in non-smokers
who have not been exposed to environmental tobacco
smoke or a smoker who has not used tobacco or
nicotine for several weeks. An alcohol test called the
EtG can detect alcohol up to 80 hours after very
extensive drinking episodes; however, in 2006, the
Substance Abuse and Mental Health Services
Administration (SAMHSA) released an advisory
saying that the EtG test was not appropriate for
assessing alcohol use because it is highly sensitive
and unable to distinguish between alcohol absorbed
into the body from actual consumption and from
exposure to many common commercial and
household products that contain alcohol. Laboratory
tests can capture instances of other drug use for days
or weeks after use, depending on the drug.
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of errors such as false positives, contamination
or mislabeling exists.56
Given these concerns, biological tests may be
most useful in verifying conclusions drawn from
other forms of screening and assessment
instruments57 or in specific circumstances where
any substance use is sanctioned (e.g., use by
those who are underage, pregnant, have health
problems, in jobs that require sustained attention
and vigilance or by juvenile or criminal
offenders).58
Brief Interventions and Treatment
Referrals
For those who screen positive for risky use of
addictive substances that does not meet the
threshold of clinical addiction, providing brief
interventions is an effective, low-cost approach
to reducing risky use. 59
Brief interventions generally include feedback
about the extent and effects of patients'
substance use and recommendations for how
they might change their behavior.60 Brief
interventions often involve motivational
interviewing techniques f and substance-related
education; the exact approach may differ
depending on the target population.61 Brief
interventions can be conducted face-to-face,
over the phone or via computerized feedback to
patients.62 They can be performed by health
professionals after relatively limited training.63
Providing brief interventions can save lives and
reduce a broad range of negative health and
social consequences including addiction.
e.g., truck drivers, air traffic controllers, physicians.
' Motivational interviewing is a patient-centered
approach to counseling. Counselors attempt to
initiate behavior change through reflective listening.
They help patients resolve any ambivalence toward
reducing their substance use through an empathetic
discussion of the discrepancies between their values
and self-image and their current substance use
behavior. Counselors stress ideas of self-efficacy and
optimism to their patients. (For a more detailed
discussion, see Chapter V.)
For individuals showing signs of addiction,
providing treatment or referral to specialty care*
is critical to managing the condition and
preventing further health and social
consequences.64
Tobacco
Brief interventions for smoking and other
tobacco use can be provided by trained health-
care practitioners and generally occur in clinical
and primary-care settings.65 According to
clinical guidelines, practitioners should provide
brief interventions based on the "Five A's":
• Ask. The process begins with inquiries
about tobacco use, which should be made
during every visit.
• Advise. Individuals who smoke should be
advised in a clear, strong and personalized
manner to quit.
• Assess. Practitioners should determine
whether or not a patient is willing to attempt
to quit.
• Assist. If the patient is willing to attempt to
quit, the practitioner should provide
assistance by helping patients create a quit
plan, providing counseling and
pharmaceutical treatment recommendations,
offering problem solving and skills training
and distributing supplementary educational
materials. One intervention approach is
known as the "Five R's" where a technique
is implemented to help motivate patients to
quit smoking.66
• Arrange. Schedule follow-up contact, either
in person or by phone.67
1 See Chapters V and VI.
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The "Five R's"
Employing an empathetic counseling style,
practitioners should:
• Relevance: Encourage patients to indicate
why quitting is personally relevant.
• Risks: Help patients identify the acute,
long-term and environmental risks they take
by continuing to smoke.
• Rewards: Help point out the rewards that
will come with cessation.
• Roadblocks: Ask patients to identify any
roadblocks they may face during their
attempt to quit and suggest potential
solutions for each.
• Repetition: Repeat this process every time
they see the patient.
Brief interventions for smoking cessation should
include a follow-up visit scheduled shortly after
a patient's quit date.68
A more simple approach that is gaining traction
is to restrict the brief intervention to the first two
"A's"— Ask and Advise— and then refer the
patient, usually to a telephone quitline or a
smoking cessation service, where the other three
"A's" are performed.69 A recent review of
research found that compared to just providing
advice, physicians who offered assistance in
quitting to all patients who smoke regardless of
their stated willingness to quit, could prompt an
additional 40 percent to 60 percent of smokers to
70
try quitting.
There is some evidence to suggest that shorter
interventions for smoking cessation may be
more successful than longer ones, perhaps
because of the direct, instructional nature of the
brief intervention. A study of smokers with
addiction involving alcohol enrolled in an
addiction treatment program found that 35
percent of those who received a 10-minute brief
intervention for tobacco use were abstinent a
month later compared to only 1 3 percent of
those who received a more extensive, 50-minute
In the form of counseling or nicotine replacement
therapy (see Chapter V).
motivational interview session. 1 The brief
advice session directly told patients to quit
smoking and assisted participants in accessing
additional information or help to reach that goal.
In contrast, the more extensive motivational
interview focused on the advantages and
disadvantages of smoking, imagining life
without smoking, providing personalized
feedback and setting stage-specific goals.71
Alcohol and Other Drugs
Based on screening results, brief interventions
for alcohol and other drug use begin with
feedback about the quantity and frequency of a
patient's substance use, and the potential
consequences the patient may face as a result.72
Brief interventions typically involve the
counseling technique of motivational
interviewing.'1' 73
Health care practitioners trained in providing
brief intervention services try to help patients
decide to change their substance use behavior in
light of the adverse medical and social
consequences of risky use of addictive
substances and the many ways in which it may
conflict with their values and goals, and then
offer advice on how patients may do so.74
The advice for adults5 may include:
• Setting a specific limit on consumption;
• Learning to recognize the antecedents of
substance use and developing skills to avoid
use in those situations;
1 After six months, the abstinence rates of both
groups had fallen to 13 percent and two percent,
respectively.
* See Chapter V.
§ Given the dangers of substance use during the
vulnerable period of brain development that
continues into young adulthood, the advice for
adolescents and young adults who have not reached
the legal ages for smoking or drinking alcohol,
should focus less on limiting risky use and more on
abstaining from use of all addictive substances.
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• Planning ahead to limit drinking and other
drug use;
• Pacing one's use; and
• Learning to cope with the everyday
problems that may lead to substance use.75
Helping patients understand how they can
change their behavior and encouraging them to
be optimistic about their ability to do so are
important components of most brief
interventions.77 Interventions delivered in an
empathetic counseling style are more effective
than those that rely on confrontation or
coercion.78 While brief interventions can avert
the development of a more serious substance use
problem,79 individuals with the disease of
addiction require more intensive care and should
be treated or referred to specialty care.
Effectiveness of Screening and Brief
Interventions
The combination of screening and brief
interventions has shown positive results for
tobacco,80 alcohol,81 illicit drugs and the misuse
Sometimes referred to as SBI.
of controlled prescription drugs, across many
settings and population groups. f 83
Several large-scale studies have explored the
effectiveness of screening and brief
interventions in reducing the consumption of
addictive substances as well as the serious
problems and costs that accompany such
behavior, including visits to emergency
departments, hospitalization, high-risk injection
drug use, criminal activity, psychiatric stress
and depression.84 One study found that adult
patients1 receiving a brief intervention after a
positive screen by their primary care physicians
for risky alcohol use experienced 20 percent
fewer emergency department visits and 37
percent fewer days of hospitalization than
patients who did not receive the intervention.85
Participants who received screening and brief
interventions also had significantly fewer arrests
for alcohol or controlled drug violations (two vs.
1 1 arrests).86
A large-scale study conducted in a broad range
of medical settings across six states found that
22.7 percent of the patients in the study screened
positive for risky alcohol or other drug use or
addiction. Sixteen percent of the patients who
were screened received a recommendation for a
brief intervention, 3.2 percent received a
recommendation for brief treatment and 3.7
percent received a referral to specialty
' It is difficult to compare the effectiveness rates of
different research trials and programs as many of
them use restricted populations and vary in the length
and intensity of the intervention. Despite these
methodological discrepancies, there are strong data
showing the effectiveness of screening and brief
interventions in addressing risky use of addictive
substances. Studies reporting successful outcomes
tend to reflect situations where participation was
voluntary and may not reflect outcomes in a
population with mandatory participation.
Furthermore, most of these studies examine the use
of screening and brief interventions in primary care
settings as it pertains to alcohol use and not to other
drug use.
* Between the ages of 1 8 to 65 who visited a
physician's office for routine care.
"FRAMES":
Key Elements of a Brief Intervention for
Reducing the Risky Use of
Alcohol and Other Drugs76
A frequently -used brief intervention for the risky
use of alcohol and other drugs includes six core
elements identified and verified through
empirical research that can be summed up by the
acronym "FRAMES":
• Feedback regarding personal risk or
impairment;
• Responsibility for change;
• Advice to change;
• Menu of options for reducing substance use;
• Empathetic counseling style; and
• Self-efficacy in terms of ability and
responsibility to change.
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treatment. The study found that brief
interventions, brief treatments or referrals to
specialty treatment for those who screened
positive for risky alcohol and/or illicit drug use
at baseline were associated with a 38.6 percent
reduction in rates of heavy alcohol use and a
67.7 percent reduction in rates of illicit drug use;
however, it is important to note that this study
was not a randomized controlled trial.87
Screening and brief intervention services also
have proven effective in increasing entry rates to
specialized addiction treatment programs for
patients with addiction88 and for patients who
are required to wait to enter standard treatment
programs.89
Tobacco
When clinics and medical offices require
screening for tobacco use, tobacco-using
patients are likelier to achieve smoking
cessation. This may be because clinics and
medical offices that have tobacco screening
systems in place are approximately 1.7 times as
likely to provide smokers with interventions as
offices that do not require patients to undergo
tobacco screening.90
A systematic review of 3 1 studies examining the
effects of smoking interventions provided by
nurses in hospital settings found that the
smoking cessation rate of patients who received
brief interventions was 1.3 times the cessation
All patients in the study were screened for alcohol
and other drug use; however, different instruments
were used in each study site and the thresholds for
being classified as being a risky substance user varied
considerably among the sites. Those with moderate
risk substance use patterns received brief
interventions such as the FRAMES intervention or
motivational interviews; those with heavy use
patterns received brief treatment which consisted of
brief but more intense interventions such as enhanced
motivational interviews (MI), motivational
enhancement therapy (MET) or cognitive behavioral
therapy (CBT) (see Chapter V for an explanation of
these therapies); and those who met clinical criteria
for addiction were referred to specialty treatment.
There was no control or comparison group in this
study.
rate of control group patients. Another large-
scale study found that smokers who reported that
they had received a brief smoking cessation
intervention from their primary care provided
were more than three times likelier to quit
smoking than those who did not receive such
counseling (34.9 percent vs. 10.5 percent among
patients without co-occurring addiction
involving alcohol or other drugs or mental health
disorders and 31.3 percent vs. 6.0 percent among
those with such co-occurring conditions).92
Alcohol
Screening and brief interventions for risky
alcohol use have demonstrated efficacy in
primary care and emergency/trauma settings.93
One study, conducted in a primary care setting
with patients who screened positive for risky
alcohol use, found a greater decline in the
number of people who reported binge drinking5
among those receiving a brief intervention (from
85.0 percent at baseline to 61.5 percent three
years after the first intervention) compared to
those in the control group (from 86.9 percent at
baseline to 70.7 percent three years after the first
intervention). Likewise, there was a greater
decline in the number of people who reported
heavy drinking' ' among those receiving the brief
intervention (from 46.7 percent at baseline to
23.2 percent three years after the first
intervention) compared to those in the control
' The effects of the interventions appear to be
strongest among cardiac rehabilitation patients.
* As indicated by a positive response to the question,
In the past 12 months, did any of the general medical
providers talk to you about quitting or avoiding
smoking?
§ Defined in this study as consuming more than five
drinks on one occasion during the previous 30 days.
The brief intervention included a health
information booklet, two face-to-face, 15-minute
intervention sessions with a physician spaced one
month apart and two follow-up calls from nurses
during the weeks following their interventions; the
control group only received the information booklet.
Patients were randomly assigned to one of these two
conditions.
^ Consuming more than 20 drinks during the past
week for men and more than 13 drinks during the
past week for women.
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group (from 49.2 percent at baseline to 34.6
percent three years after the first intervention).
The intervention participants also experienced
55 percent fewer nonfatal motor vehicle crashes
and 46 percent fewer arrests.94 Another study
found that a 30-minute brief intervention was
associated with significantly fewer at-risk
patients being arrested for driving under the
influence of alcohol during the next three years
(1 1.3 percent of brief intervention patients had a
DUI arrest vs. 21.9 percent of control group
patients).95
A systematic review of emergency department-
based screening and brief intervention programs
found that 82 percent of the studies included in
the review demonstrated a positive effect. ' 96
Even in non-emergency cases and cases
seemingly unrelated to substance use (e.g.,
general surgery and anesthesia consults),
routinely screening all pre-surgical patients for
risky use and addiction can prevent
complications from surgery, and brief
interventions or referral to treatment can prevent
the presenting condition from worsening.97
Brief interventions conducted in trauma centers
for patients who engage in risky alcohol use
have been associated with a 47 percent reduction
in re-injuries requiring emergency department or
trauma center admission and a 48 percent
reduction in re-injuries requiring hospital
admission.98 Brief interventions with follow-up
are more effective than single-contact
qq . . .
interventions: a review comparing multi-
session and single-session brief alcohol
interventions found that those who received
multi-session brief interventions reported a 13 to
34 percent greater reduction in the average
number of drinks per week after six to 12
months than those receiving single-session brief
interventions.* 100
Other Drugs
Although the research on screening and brief
interventions for other drug use is quite limited
and therefore data supporting these services is
scarcer than in relation to tobacco and risky
alcohol use,101 the available research suggests
that screening and brief interventions can reduce
other drug use among patients in primary care
facilities, emergency departments, trauma
centers and other hospital units.102 In one study
conducted at six health care sites across the
country, patients who screened positive for drug
use (other than tobacco or alcohol) received
screening and brief interventions, brief treatment
or referrals to treatment based on the severity of
their drug use. Six months after receiving these
interventions, the percentage of patients
reporting past month marijuana, cocaine,
methamphetamine, heroin or other drug use-
including the misuse of prescription sedatives
and opioids as well as hallucinogens and
inhalants-decreased significantly.103 However,
this study did not contain a control condition so
the extent to which substance use would have
decreased without these interventions cannot be
determined. (Figure 4.A)
Patients in the study reported significant
increases in health status (from fair to good) and
employment (from 31.3 percent to 36.1 percent)
at the six-month follow-up as well. There also
were significant decreases in the percentage of
patients reporting past-month emotional
problems (from 25.6 percent to 17.6 percent),
arrests (from 12.2 percent to 4.4 percent) and
homelessness (from 1 1.8 percent to 6.4
percent).104
Specifically, those who have a BAC > 80 mg/dL or
a score > 8 on the AUDIT screening instrument.
* Ninety percent showed a decrease in alcohol
consumption, 13 percent showed a decrease in
emergency department visits and hospitalizations, 13
percent showed a decrease in negative social
consequences and 13 percent showed an increase in
referrals for follow-up and/or treatment.
1 Ranges rather than single values are cited because
the figures come from a meta-analysis comparing
results from multiple studies.
-73-
Figure 4. A
Pre- and Post-Past Month Use of Specific Drugs among
Patients* Exposed to Screening and Interventions
65
37
21
ft
12
• Baseline
1 6 Month Follow Up
18
10
3
5
Marijuana
Cocaine
Methamphetamine
Heroin
Other Drugs
* Who report any illicit drug use at baseline.
Source: Madras, B.K., Compton, W.M., Avula, D., Stegbauer, T, Stein, J.B.,
Clark, H.W. (2009).
Another study found that a screening and brief
intervention program* for heroin and cocaine
users implemented during a routine medical visit
was related to greater abstinence among
intervention versus control participants from
cocaine use (22.3 percent vs. 16.9 percent) and
heroin use (40.2 percent vs. 30.6 percent) six
months following the intervention.
105
Brief interventions also can reduce regular
amphetamine use. Six months after screening
positive for amphetamine use, individuals who
received brief interventions f were significantly
likelier to be abstinent than users who received
only self-help booklets. Amphetamine users
who received brief interventions also showed
decreased psychiatric distress scores and
depression levels.106
Consisting of toxicological and questionnaire
screening during routine care at an inner-city
teaching hospital, as well as brief motivational
interviews, active referrals, a list of treatment
providers and a follow-up booster phone call.
' In this study, each participant had four 45- to 60-
minute individual therapy sessions guided by a
therapist manual and a self-help booklet. The
sessions included role-play and take-home exercises,
concentrating on coping strategies and relapse
prevention. The first session focused on increasing
motivation to reduce drug use, the second on
reducing cravings through muscle relaxation and self
talk, the third on controlling thoughts about drug use
and the fourth on coping with lapses and developing
skills to use in high-risk situations.
Implementing
Screening and
Brief
Interventions in
Health Care and
Other Settings
While screening and
brief interventions can
be provided in a broad
range of venues,107
health care settings may
be the most effective.
Physicians and other
health care providers, including dental
professionals, nurses and pharmacists, typically
are a consistent, trusted and influential presence
in the lives of children and adults and their
professional position grants them the authority
and credibility to deliver effective, evidence-
based interventions to patients at risk for
complications related to their substance use,
including addiction. Part of the success of
incorporating these services for risky use of
addictive substances into standard medical
practice is that people tend to be more receptive
to health messages once they are in a health care
setting. Patients view additional screening,
information, brief intervention or referral to
treatment as part of the health care they sought
initially.108 The use of technology to assist in
the completion of screening and brief
interventions holds promise for helping to
integrate these practices into routine health care
delivery.109
Primary Care
About 80 percent of Americans4 visited at least
one physician or other health care professional
in the past year,110 and the American Society of
Addiction Medicine (ASAM) estimates that
more than two-thirds of people with addiction
are in contact with a primary or emergency care
physician about twice a year. 1 1 1 Integrating
screening and brief interventions into routine
medical check-ups can be an effective way of
Ages 1 8 and older.
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identifying smoking, risky drinking and other
drug use before negative consequences occur,
including the development of addiction.112
Although the most promising research findings
regarding the benefits of implementing these
services in health care and other settings have
been found in primary care settings, clinical
trials are lacking in this area.114 Given the
strong scientific evidence to date supporting the
use of screening and brief interventions,
particularly for smoking and risky alcohol use,
several national medical societies already have
endorsed this approach, including:
• The American Society of Addiction
Medicine (ASAM) has identified screening
and brief interventions as an effective
method for catching substance-related
problems early and preventing the
development of addiction; ASAM
encourages medical and insurance
professionals to redesign their primary care
and funding practices to accommodate these
programs.115
• The American Academy of Family
Physicians recommends that adults,
including pregnant women, be screened for
tobacco use and provided with cessation
interventions or brief counseling and that
screening and brief interventions for alcohol
use be used in health care settings as well.116
• The American College of Obstetricians and
Gynecologists' Committee on Ethics
declared that obstetrician-gynecologists
have an ethical obligation to conduct
universal screening, brief intervention and
referral to treatment for their patients.117
• The American Dental Association advises
dentists to address the issue of risky use and
addiction with patients and refer them to
appropriate addiction treatment if needed.118
Even the United States Preventive Services Task
Force (USPSTF), which is constrained by
available medical evidence, has recommended
screening and brief intervention for risky alcohol
use for all adults in primary care settings,* 119
and that all adults, including pregnant women,
be screened for tobacco use and receive
appropriate cessation counseling/ 120 And, the
National Quality Forum has endorsed screening
and brief interventions for tobacco and alcohol
use in general health and mental health-care
1 21
settings.
Adolescent Health Care. Screening the
adolescent population for substance use may be
the single most effective preventive step that can
be taken to address the problem of risky use and
The USPSTF recommends this service with a B
rating, indicating that the net benefits of the
intervention outweigh any potential harms.
' The USPSTF recommends this service with an A
rating, indicating that the net benefits of the
intervention substantially outweigh the harms; for
pregnant women, the Task Force recommends that
the counseling services be tailored to pregnancy. As
a result of limited research on the topic, the USPSTF
concluded that there currently is insufficient clinical
evidence to determine the balance of benefits and
harms of routine (asymptomatic) screening or
interventions for tobacco or alcohol use among
adolescents or for screening individuals for illicit
drug use in primary care practice settings. A recent
report by the USPSTF, however, identified 1 1 high-
priority areas in preventive medicine that have
critical evidence gaps that, if addressed through
targeted research, are likely to result in
recommendations for practice. Among these 1 1
high-priority areas are screening and providing
counseling for adolescent alcohol use and screening
all individuals for illicit drug use.
The 2010 National Drug Control
Strategy Recommends:
• Increasing health care providers'
knowledge and use of screening and brief
intervention techniques through enhanced
medical and nursing school educational
programs;
• Increasing screening and early intervention
for substance use in all health care settings;
and
• Increased reimbursement for screening and
brief interventions in primary care.113
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addiction in this country since the consequences
of risky use of addictive substances among
adolescents are so profound and individuals with
addiction typically began engaging in risky use
in adolescence.122
The primary care office is a key setting for
adolescent screening and brief intervention
related to substance use; using computer
technology to achieve these ends meets the needs
of both patients and physicians by making the
process more efficient and easier for physicians,
producing more honest responses from patients,
and increasing both providers' and patients'
satisfaction with the encounter. 126
--John R. Knight, MD
Director,
Center for Adolescent Substance Abuse Research
Associate Professor of Pediatrics,
Harvard Medical School
Senior Associate in Medicine,
Associate in Psychiatry,
Children's Hospital Boston
> Be knowledgeable about addiction and
skilled in recognizing the risk factors for
substance use among young people;
> Screen all patients for substance use at
annual medical examinations and, if
possible, at other medical visits as well
using screening methods that are
validated, nonjudgmental and that
protect confidentiality;
> Provide brief interventions and refer
patients, when necessary, to treatment or
specialty care;
> Consider and address co-occurring
disorders; and
> Promote substance use prevention
programs and media responsibility with
regard to depictions of substance use.127
Emergency and Trauma Care
The U.S. Public Health Service's clinical
practice guideline for tobacco use and
dependence recommends that clinicians ask
adolescent patients about their tobacco use and
provide them with brief interventions to aid in
quitting.123
Professional medical associations such as the
American Medical Association (AMA) and the
American Academy of Pediatrics (AAP) support
screening adolescent patients for substance use,
and promote the use of screening and brief
intervention techniques among their
124
constituents:
• The AMA' s Guidelines for Adolescent
Preventive Services recommend that
physicians ask all adolescents annually
about their use of tobacco, alcohol and other
drugs, including over-the-counter drugs,
controlled prescription drugs and anabolic
steroids.125
• The American Academy of Pediatrics
(AAP) encourages pediatricians to:
Emergency Departments (EDs) and trauma
centers are particularly critical venues for
screening and brief intervention since so many
emergency and trauma cases involve risky
substance use. One study found that up to 3 1
percent of all patients treated in hospital EDs
who were screened for risky alcohol usef had a
positive result. + 128 Many trauma patients meet
criteria for addiction; a study of seriously injured
trauma patients shows that 24.1 percent of them
met diagnostic criteria for alcohol dependence
and 17.7 percent for other drug dependence}29
Further, substance-using individuals frequently
rely on EDs for much of their health-care
Fifty percent of severely injured trauma patients and
22 percent of minor trauma patients receive their
injuries under the influence of alcohol.
' Based on the CAGE questionnaire.
* Fhis most likely is a conservative estimate since
many EDs do not screen for alcohol or other drug use
because of insurance laws (i.e., the Uniform Accident
and Sickness Policy Provision Law-UPPL) restricting
payment if the reason for admission was substance
related.
-76-
EDs and trauma centers are ideal settings for the
"teachable moment" that is thought to be one of
the key components of the positive impact of a
brief intervention.131 Most individuals who
experience substance-related accidents and
injuries do not meet clinical criteria for
addiction132 but are excellent candidates for brief
interventions. One study of young adults
admitted to a hospital emergency department
found that those who were alcohol-involved
and who received a brief motivational
intervention followed by two telephone booster
sessions showed greater reductions in alcohol
use than those who just received one to three
minutes of feedback, in which they were
provided information about how much they
drink, what happens when they drink and how
their alcohol intake compares to their peers (a
reduction of up to 53 percent vs. 18 percent).133
ED and trauma physicians were some of the first
to recommend the adoption of screening and
brief interventions;134 their focus to date has
been on excessive alcohol use which is the
leading risk factor for injury:135
• The American College of Emergency
Physicians recommends screening and brief
interventions for alcohol use.136
• The American College of Surgeons
Committee on Trauma requires that Level I
and Level II trauma centers have a
mechanism in place to identify patients who
Screened positive for alcohol use, reported drinking
in the six hours before their accident or had a history
of risky drinking (as determined by their AUDIT
score).
engage in risky alcohol use and Level I
Centers must have a mechanism in place to
intervene with these patients.1" 137
An important point of access to the health care
system for adolescents is through the ED;
approximately 12.7 percent of substance-related
ED visits are made by individuals ages 12 to 20
years old (5.7 percent by those ages 12 to 17 and
7.0 percent by those ages 18 to 20). 138
Interventions conducted in the ED may reach
adolescents who do not attend school regularly
or who do not have a primary care physician.139
Health Care for Pregnant Women*
Given the considerable impact of substance use
on reproductive health and pregnancy, women
(especially those who are pregnant or of
reproductive age) are an ideal target for
screening and brief intervention services.141
Because there is no universally safe level of
substance use during pregnancy, any use should
be screened for and addressed. The American
College of Obstetricians and Gynecologists
recommends that because of these risks, all
women— regardless of present pregnancy status-
should be screened for alcohol use at least yearly
and provided with intervention and referral
services if necessary.142
One study found that pregnant smokers who
received brief counseling and behavioral
interventions in a public maternity hospital had a
higher rate of smoking abstinence (33.3 percent)
than pregnant smokers who received usual care
(8.3 percent).143 Another study found that
pregnant smokers in community health centers
who received brief interventions were more
likely to be abstinent by the end of their
pregnancy than women receiving usual prenatal
care (past-month abstinence rate of 26 percent
vs. 12 percent). However, in this study, the
higher rates of smoking abstinence following a
1 The focus in this area primarily has been on alcohol
rather than tobacco or other drugs.
* Research on screening and brief interventions for
pregnant women focuses primarily on tobacco and
alcohol use. No studies of the use of such services in
pregnant women who use other drugs were found.
Research [related to screening and brief
intervention] began in the ED. The earliest
study— conducted in 1957— was a controlled trial
with 200 dependent drinkers at Massachusetts
General Hospital. Patients who had a
nonjudgmental, respectful conversation inviting
them to attend an outpatient program were more
likely than other patients to complete one
appointment (65.0 percent vs. 5.4 percent) and
five appointments (42.0 percent vs. 1.1
percent).140
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brief intervention disappeared at three and six-
month post-partum follow-ups,144 indicating a
need for more intensive treatment services.
Screening and brief interventions in prenatal
care settings have been found to reduce alcohol
use significantly,145 as well as the chances of
low birth-weight deliveries.146 Brief
interventions for alcohol use among pregnant
women are effective even when provided in a
community setting by non-medical
professionals.147 Programs that include spouses
and partners are particularly effective.148
Mental Health Care
Despite the high rate of co-occurring addiction
and mental health disorders,149 screening and
brief interventions for risky substance use are
not common practice in mental health settings
and are not standard practice in the field of
psychiatry.150
There are effective tools for screening patients
with mental health conditions in mental health
settings for risky use of addictive substances151
and there is evidence that interventions can be
effective in addressing such use among those
with psychiatric conditions.152 For example, a
study evaluating the effectiveness of a screening
and brief intervention program in a primary
health and mental health care setting at a
university found that six weeks after receiving
the intervention, participants decreased their
alcohol use.* 153
Dental Care
Dental professionals can play a unique role in
detecting substance use among their patients,
providing brief interventions and referring
patients to treatment.154 Risky use and addiction
have a significant impact on multiple
components of dentistry including patients' oral
* Including the average number of drinks consumed
per week over the past 30 days, the highest number of
drinks consumed on one occasion in the past 30 days
and the number of times in the preceding two weeks
participants had consumed five or more drinks on one
occasion.
health155 and the safety of common treatments
and interventions including the prescription of
controlled medications such as opioid pain
relievers.156 The fact that dental health
maintenance and treatment require routine and
often repeated visits makes dental professionals
a consistent and potentially influential presence
in the lives of people who engage in risky use of
addictive substances.157 Dental patients are
receptive to their dentists' involvement in the
prevention and treatment of risky use and
addiction. A 2005 survey of patients visiting an
emergency dental clinic found that 80 percent
believed dentists should ask their patients how
much alcohol they drink; 90 percent believed
that dentists should warn patients to drink less
or quit if it is affecting their oral health.158
Pharmacies
The responsibilities of pharmacists with regard
to the prevention and early intervention of risky
use and addiction extend to administering
prescription medications; pharmacists are the
best source of information regarding the safe and
effective use of medications and the adverse
effects that arise from their misuse. They also
can be instrumental in controlling the diversion
of prescription medications for misuse by
monitoring the number of prescriptions filled by
a patient, looking for false or altered prescription
forms159 and recognizing when a patient is
"doctor shopping"' or in need of treatment.160
High School, College and University
Settings
Screening and brief intervention programs
reduce risky use of addictive substances among
students by changing their attitudes, beliefs and
expectations regarding tobacco, alcohol and
other drug use.161
School health programs, in collaboration with
primary care providers, are important
opportunities for screening adolescents and
young adults for substance use, primarily
1 The practice of patients visiting various health care
providers to obtain multiple prescriptions for the
drugs they misuse.
-78-
because young people spend a majority of their
time in school. Few schools, however, take
advantage of this opportunity.162 A CASA
Columbia survey of school personnel, conducted
for its 2011 report, Adolescent Substance Use:
America 's #1 Public Health Problem, found that
only 7.4 percent reported that their schools
screen all students for signs of risky alcohol or
other drug use; 9.0 percent of high school
teachers reported that their schools screen
particular groups of high-risk students for signs
of risky alcohol or other drug use.163
The college setting also is ideal for intervening
with young people at risk via screening and brief
interventions because of the high rates of
substance use in the college population; an
estimated 67.2 percent are risky users or have
addiction.' 169 To date, the majority of the
screening- and intervention-related research
among college students has focused on alcohol,
most likely because alcohol typically is the
substance most likely to be used by college
students.170 Screening and brief interventions
have proven successful in reducing risky alcohol
use and its consequences in this population.171
The Department of Education recommends the
implementation of screening and brief
intervention programs in all college health
1 7?
centers.
Brief Alcohol Screening and Intervention
of College Students (BASICS) Program
The BASICS program targets risky drinkers
(defined as those who drink heavily and are at
risk for or already have experienced problems
related to alcohol use) between the ages of 18
and 25. 164 Students are identified for
participation in the programs through screening
or through referral from medical, housing or
disciplinary services. 165 The program consists of
two one -hour interviews and a brief online
assessment survey about drinking habits and
history, as well as beliefs and attitudes, while
giving instructions for monitoring one's own
drinking between interviews. In the second
interview, students receive personalized face-to-
face feedback about their alcohol use compared
with peer norms, consequences of and risk
factors for drinking and strategies for reducing
alcohol use and related problems. 166 The
BASICS program has proven to be effective and
cost-effective.167 In one study, students who
received the BASICS intervention as college
freshmen were more likely than risky drinkers
who did not participate in the intervention to
have reduced their alcohol consumption four
years later (67 percent vs. 55 percent).168
Justice Settings
Juvenile justice programs and facilities are ideal
venues for screening and brief interventions;
CASA Columbia's 2004 report, Criminal
Neglect Substance Abuse, Juvenile Justice and
The Children Left Behind, found that four of
every five children and adolescents in the
juvenile justice system are substance
involved.* 173 Unfortunately, jurisdictions
typically do not provide adequate screening or
brief intervention services174 even though there
are several screening tools that have been
validated for use with juvenile offenders.175
Of enrolled college students, ages 18-22.
1 43.9 percent are risky users but do not have
addiction and 23.3 percent have addiction, i.e., meet
clinical diagnostic criteria for past month nicotine
dependence and/or past year alcohol and/or other
drug abuse or dependence.
x Under the influence of alcohol or other drugs while
committing their crime, test positive for drugs, are
arrested for committing an alcohol or other drug
offense, admit to having a substance use problem or
share some combination of these characteristics.
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One national study of juvenile residential
facilities found that 1 5 percent of the facilities
that reported information about evaluating
residents for substance-related issues indicated
that they did not screen at all, 20 percent
reported that they screened some youth and 64
percent reported that they screened all youth; 4 1
percent reported using a standardized screening
instrument. 7 Even those facilities that screen
youth and use a standardized screening
instrument do not necessarily provide
appropriate interventions or treatment based on
screening findings.177
The criminal justice system includes even higher
concentrations of individuals whose crimes are
linked to their use of alcohol and/or other drugs.
CASA Columbia's 2010 report on substance use
in this population, Behind Bars II: Substance
Abuse and America 's Prison Population, found
that 84.8 percent of inmates in America are
substance involved.1 178 Screening can be used
to identify those in need of intervention and to
make appropriate referrals to treatment, which
ultimately can help to reduce crime and prison
overcrowding and save taxpayer money.179
Despite abundant evidence of the efficacy of
screening and brief interventions,180
standardized screening and interventions are not
implemented regularly injustice settings.181
Although inmates are guaranteed the right to
medical care,182 they routinely are denied access
to appropriate screening, intervention and
treatment services for the disease of addiction.183
The Workplace
The majority of people ages 18 and older who
meet clinical criteria for addiction (63.8 percent)
Of the 2,658 facilities in the final sample, 2,128
reported information about screening.
1 Substance-involved inmates are those who either
had a history of using illicit drugs regularly; met
clinical criteria for addiction; were under the
influence of alcohol or other drugs when they
committed their crime; had a history of alcohol
treatment; were incarcerated for a drug law violation;
committed their offense to get money to buy drugs;
were incarcerated for an alcohol law violation; or had
some combination of these characteristics.
or who engage in risky use but do not have
addiction (73.0 percent) are employed full or
part time;184 individuals who engage in risky
substance use or are addicted have higher rates
of absenteeism, decreased work productivity and
higher health care costs.185
If approached as a health issue, the workplace is
an ideal venue for offering confidential
screening, brief interventions and treatment
referrals. Workplaces increasingly rely on
Employee Assistance Programs (EAPs)186—
confidential counseling programs for employees
that offer assistance with health or other
problems that can adversely affect job
performance.187 One recent survey of human
resource professionals found that 60 percent
reported that their organizations offered
employee wellness programs and 42 percent had
health screening programs.188 Only recently,
however, have there been attempts to utilize
EAPs and similar workplace programs to
provide screening and brief intervention services
to employees.189
Researchers have demonstrated that providing
these services to employees who contact an EAP
program for assistance can be effective at
identifying risky use and addiction.190 Several
pilot studies3- have demonstrated the
effectiveness of identifying risky drinking5
among employees via EAP services and of
having those who were identified agree to
follow-up counseling.191 According to a
national employer survey, however, only 29
percent of employers offer screening to their
employees for risky alcohol use and 60 percent
of that group provide brief interventions.192
Comparable data on the proportion of employers
that screen or provide interventions for
employees who smoke or use other drugs are not
available.
J Conducted in partnership with Aetna and
OptumHealth.
§ Using the AUDIT.
** Of the employers that provide screening, most
reported using the EAP, human resources,
occupational health and safety and educational
outreach programs to conduct the screening.
-80-
Unfortunately, much workplace screening takes
the form of drug testing and is used for
compliance purposes. In this light, it frequently
is viewed as infringing on workers' privacy;193
workers may worry about the confidentiality of
their test results and whether they will be used to
deny employment or to impose other forms of
discrimination.194 The drug- testing process can
be costly as well.195 In conducting workplace
drug testing, the American Society of Addiction
Medicine (ASAM) recommends that a positive
drug test be used only as evidence that substance
use occurred, not as evidence of functional
impairment or addiction; the interpretation of
drug test results should include the use of a
credentialed Medical Review Officer; and
controlled prescription medications should be
included in the screening.196
Government-Funded Social Service
Systems
Government agencies can play an important role
in providing screening and brief interventions to
a range of clients including those receiving
housing, welfare and child protection, services
for the elderly, and in HIV and STD clinics.197
Government- funded social service systems can
identify substance use risk in individuals
participating in their programs and provide
interventions, treatments or referrals to specialty
care when addiction is identified.
A significant proportion of individuals who
participate in government programs have many
risk factors for substance use and addiction and
can benefit from screening and brief intervention
services. Identifying individuals at risk and
providing effective interventions for those in
need may help to reduce their risk of further
substance use, job loss, domestic violence and
other crime and, ultimately, can lead to cost-
savings through decreased demand for
government services.198 Despite the logic of this
approach, there is little research on the
effectiveness of screening and brief
interventions in these populations and, instead of
implementing these services, some states are
now imposing or considering drug testing as a
precondition for cash assistance and other
services and a basis for denying both program
eligibility and needed medical care.* 199
Barriers to Effective
Implementation of Screening and
Brief Interventions
The failure of our health care providers, schools,
employers, justice programs and social service
programs to implement effective screening, brief
interventions and treatment referrals for those
who engage in risky use of addictive substances
represents a tremendous missed opportunity to
help countless Americans avoid the far-reaching
consequences of risky use and the disease of
addiction. A significant barrier to change is the
fact that services aimed at preventing and
addressing risky use and addiction traditionally
have not been paid for by health insurance plans;
as a result, there are few incentives for health
professionals to make them a priority in the care
of their patients. To close the gap in needed
services, specific barriers in addition to
insufficient funding must be addressed,
including insufficient training of health care and
other professionals and a lack of specialty care
providers; competing priorities and insufficient
resources; and inadequate screening tools.200
Insufficient Training
Many physicians and other health professionals
do not screen their patients for risky use of
addictive substances, provide early interventions
or treat or refer for specialty care, or they do so
inadequately because they simply have not been
properly trained.1 Education about risky use and
the disease of addiction, their impact on a
patient's health and other medical conditions,
and how to implement screening, interventions
and treatment is not sufficiently integrated into
medical education or residency training
programs.201 Among those programs that do
address substance use and addiction, many have
shortcomings in the curriculum such as
insufficient instruction, limited number of
The Constitutionality of these policies is being
tested in the courts.
1 See Chapters IX and X.
-81-
courses and limited time spent in courses on the
topic of addiction.202
Inadequate training in risky use and addiction
means that many physicians do not recognize
these conditions in their patients, do not believe
that substance-related interventions are
effective,203 are unaware of what do with a
patient who screens positive for risky use or
addiction or are uninformed about effective
resources to which they could refer patients in
need of more in-depth assessment or of specialty
treatment.204
Most schools lack employees or consulting
personnel with the necessary training and
resources for identifying students who engage in
risky use of addictive substances and attaining
appropriate intervention services for those
students who need them.205 CASA Columbia's
survey of school personnel conducted for its
201 1 report, Adolescent Substance Use:
America 's #1 Public Health Problem, found that
three-fourths of teachers are unable to identify a
professional in their schools who would be able
to help students with a substance use problem.
Only 26.9 percent of teachers report that their
schools train educators and other school staff to
identify and respond to student substance use.206
Other national surveys likewise find that high
school counselors and school psychologists
generally report low competence in providing
direct substance-related intervention services to
students and a lack of relevant opportunities to
become trained in doing so.207 Most schools
have not set up partnerships with health care
providers trained in conducting screening or
early interventions to refer students who engage
in risky use nor do they have links to appropriate
treatment programs to which they refer students
with addiction.208
CASA Columbia's 1999 report, No Safe Haven:
Children of Substance-Abusing Parents, found
that insufficient training among most child
welfare workers and family court judges greatly
contributes to the lack of effective screening
practices in the child welfare system.209 CASA
Columbia's research, published in its 2010
report Behind Bars II: Substance Abuse and
America's Prison Population, found that
probation and parole officers in the justice
system need to be better trained as well.210
A related barrier to screening for risky use of
addictive substances and providing brief
interventions is the lack of effective and
appropriate specialty treatment services
available for referral when addiction is
identified.211 Although having more trained
addiction physician specialists is critical to
providing care for those with severe forms of the
disease, the lack of such specialty providers is
not a legitimate barrier to providing screening
and brief interventions. Neither is it a legitimate
reason for general health care professionals to be
unprepared to provide addiction treatment that
does not require specialty care. These services
are designed to be provided in non-specialty care
settings, along with some forms of assessment
and treatment (see Chapter V). The real barrier
in this case remains the lack of knowledge about
risky use and addiction and insufficient training
in addressing these issues among health
professionals.
Competing Priorities/Insufficient
Resources
Lack of time and resources in the face of
competing priorities is one of the most
prominent barriers to implementation of
screening and brief interventions among health
213
professionals, school personnel and
214
government agencies.
Because the general model in medicine today
(which is reflected or driven by insurance
reimbursement structures) is procedure-oriented
and reactive more than preventive, and because
insurance coverage for screening and brief
interventions for substance use has been rare,*
these services end up falling low on most
physicians' lists of competing priorities for their
time and attention.215
Schools and government agencies that
administer justice programs or provide social
services also face competing priorities and
financial constraints that serve as barriers to
See Chapter VIII.
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their implementation of screening and brief
intervention services.216 Too often, state
policymakers or administrators of these
programs fail to understand how risky use and
addiction impede progress in achieving their
organizational goals.
The priorities of protecting patient
confidentiality and maintaining an amicable and
trusting doctor-patient relationship also may
impede health professionals' implementation of
these practices.217 While existing federal
regulations* protect the privacy of patients
receiving addiction-related services in settings
that are federally assisted and that are primary
providers of these services, the regulations do
not apply to other service venues.218 These
ambiguous rules serve as a disincentive to health
professionals to offer screening and brief
intervention services and an incentive to keep
substance-related services divorced from
mainstream medicine.219
Inadequate Screening Tools
Another barrier to the effective implementation
of screening and brief intervention has been that
widely-used screening tools do not adequately
identify the full range of incidences of risky
use.1 These tools also do not follow consistent
standards nor are they designed to be tailored to
the unique patterns, symptoms and
consequences of substance use of different age
groups, genders, races/ethnicities and cultures or
of individuals with co-occurring conditions, for
whom a lower level of use may constitute risk
relative to an average respondent.1 220 Further,
most screening instruments focus on specific
substances independently rather than identifying
risky use of all addictive substances or risk for
addiction as a unified disease. Reliance on
Known as 42 CFR, Part 2 (Confidentiality of
Alcohol and Drug Abuse Patient Records).
1 See Appendix H.
* For example, any use of addictive substances by
children, adolescents or pregnant women constitutes
risky use; risky alcohol use is defined differently for
women vs. men; and substance use by some
individuals with co-occurring health conditions poses
extreme risks even at levels that may be considered
relatively safe among those without such conditions.
instruments that screen only for one type of
substance increases the likelihood that risky use
will not be adequately detected or that
interventions will fail to reduce risky use across
the board.
Only a few screening instruments have
undergone rigorous scientific examination to
determine their reliability, validity, sensitivity
and specificity-key elements determining the
effectiveness of such instruments.5 221 Rather
than using objective and standardized measures
of risky use and risk for addiction, many of the
more commonly-used screening instruments
determine risk by relying on respondents'
subjective reports of their own reactions to their
use of addictive substances and the reactions of
those around them, or their experiences of
adverse social and health consequences
associated with such use. For example, while
risky alcohol use commonly is defined simply as
drinking in excess of the established dietary
guidelines of no more than one drink per day for
women and two drinks per day for men, the
CAGE Questionnaire simply asks four items
related to the respondent's alcohol use--(l) Have
you ever felt you should Cut down on your
drinking? (2) Have people Annoyed you by
criticizing your drinking? (3) Have you ever felt
bad or Guilty about your drinking? (4) Have you
ever had a drink first thing in the morning to
steady your nerves or to get rid of a hangover
(Eye-opener)?222— none of which assesses
directly the quantity and/or frequency of use.
Likewise, the CRAFFT, a six-item questionnaire
for screening adolescents for risky alcohol and
other drug use (excluding nicotine) asks: (1)
Have you ever ridden in a Car driven by
s See Appendix H. Reliability is whether the
instrument produces the same results under the same
conditions when taken on multiple occasions.
Validity is how accurately the instrument measures
what it is intended to measure. Sensitivity refers to
an instrument's ability to identify correctly the
presence of a condition; the higher the sensitivity the
less likely the instrument is to produce false
positives. Specificity is an instrument's ability to
identify correctly those without the condition; the
higher the specificity, the less likely the instrument is
to produce false negatives.
-83-
someone (including yourself) who was high or
had been using alcohol or drugs? (2) Do you
ever use alcohol or drugs to Relax, feel better
about yourself or fit in? (3) Do you ever use
alcohol or drugs while you are by yourself
Alone? (4) Do you ever Forget things you did
while using alcohol or drugs? (5) Do your
Family or Friends ever tell you that you should
cut down on your drinking or drug use? (6) Have
you ever gotten into Trouble while you were
using alcohol or drugs? An affirmative answer
to each question is worth one point and a cut-off
score of two is recommended for identifying
risky alcohol and other drug use,223 even though
any use of addictive substances by adolescents is
considered risky.224
The typical screening process also may fail to
distinguish those individuals with a higher level
of substance involvement and the associated
health and social consequences (including the
risk for addiction) from those with lower levels
of involvement— a distinction necessary for
providing appropriate interventions.225
Chapter V
Treatment and Management of Addiction
Addiction is a disease that can be treated and
managed effectively at venues where regular
medical care is delivered by physicians,
including addiction physician specialists, and
including a multi-disciplinary team of other
health professionals using an array of evidence-
based pharmaceutical and psychosocial f
approaches. In accordance with standard
medical practice for the treatment of other
chronic diseases, best practices for the effective
treatment and management of addiction must be
consistent with the scientific evidence of the
causes and course of the disease. Best practices
require:1
• Comprehensive assessment of the extent
and severity of the disease, determination of
a clinical diagnosis, evaluation of co-
occurring health conditions and the
development of a tailored treatment plan;
In this report, we have used the general term
addiction to apply to those who meet criteria for past-
month nicotine dependence based on the Nicotine
Dependence Syndrome Scale (NDSS) and those who
meet diagnostic criteria for past year alcohol and/or
other drug abuse or dependence (excluding nicotine)
in accordance with the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV). (The DSM
refers to substance abuse and substance dependence
collectively as substance use disorders. The criteria
for nicotine dependence in the NDSS parallel those
of the DSM-IV.) This definition is consistent with
the current move to combine abuse and dependence
into an overarching diagnosis of addiction in the
upcoming DSM-V.
f Psychosocial therapy is a general term for non-
pharmaceutical-based interventions and includes
various forms of individual and group psychotherapy
that address psychological, behavioral and social
issues that contribute to risky substance use and
addiction. Behavioral therapies are those
psychosocial interventions that focus more directly
on addressing the patient's substance-related
behaviors, typically through behavioral reinforcement
approaches, with less of an emphasis on the
psychological or social determinants of their
substance use.
-85-
• Stabilization of the patient's condition via
cessation of substance use and medically
supervised detoxification, when necessary,
as a precursor to treatment;
• Acute Care via evidence-based
pharmaceutical and/or psychosocial
addiction treatments, accompanied by
treatment for co-occurring health conditions,
delivered by qualified health professionals;
• Chronic Disease Management to help the
patient maintain the progress achieved
during acute treatment and prevent relapse.
The process should be medically supervised
and should involve pharmaceutical and/or
psychosocial therapies and continued
management of co-occurring health
conditions as indicated; and
• Support Services including encouragement
to participate in mutual support programs
and the provision of auxiliary support
services such as legal, educational,
employment, housing and family supports.
A Comprehensive Approach to
Treatment
A comprehensive approach to addiction requires
recognition of addiction as a primary disease and
that all substances and behaviors associated with
addiction are addressed in treatment, rather than
a focus only on an individual addictive
substance. It is all too common, for example,
for addiction involving nicotine to be ignored in
the course of treating addiction involving
alcohol or other drugs. Accordingly, when
treating addiction, it is critical to recognize the
high rates of co-occurrence of different
manifestations of addiction and the possibility of
the existence of an addiction syndrome, in which
common pathways underlie related addictive
behaviors (e.g., obesity or bulimia and addiction
involving alcohol) and in which individuals may
switch from one object of addiction* to another
(e.g., from prescription opioids to heroin, from
addictive substances to pathological gambling).5
Including the source of reward or relief.
Similarly, treatments for one manifestation of
addiction tend to have spillover effects, either
ameliorating the symptoms of other
manifestations of addiction or proving effective
in the treatment of multiple expressions of
addiction (e.g., naltrexone for the treatment of
addiction involving opioids, alcohol as well as
gambling).6
When treatment is too highly focused on a
specific substance or behavior, it may not be
addressing the actual underlying causes of the
addiction or the possibility of "addiction
Numerous studies have shown that addiction
treatments are just as effective as those for other
illnesses.2
-Alan I. Leshner, PhD
Chief Executive Officer
American Association for the
Advancement of Science
Executive Publisher, Science
Former Director
National Institute on Drug Abuse (NIDA)
/7 would define treatment for addiction] the way I
would define treatment for any medical problem-
good thorough evaluation, intervention tailored
for that specific person based on a good
assessment, use of a range of tools— behavioral,
pharmacological, family and other social support,
housing, jobs?
—John Rotrosen, MD
Professor, Department of Psychiatry
New York University School of Medicine
VA NY Harbor Healthcare System
The goal of the 'good and modern ' system is to
provide a full range of high-quality services that
meet the range of age, gender, cultural and other
circumstances that the individual brings to
treatment. It is grounded in a public health model
that addresses system and service coordination;
health promotion and prevention, screening and
early intervention; treatment and recovery; and
resiliency supports to promote social integration
and optimal health and productivity?
~H. Westley Clark, MD, JD, MPH
Director
Center for Substance Abuse Treatment, SAMHSA
-86-
hopping," where a patient replaces one addiction
object with another. Treating the disease of
addiction involves addressing not only the
specific object of the addiction, but the
antecedents, manifestations and consequences of
addiction more generally.7
addiction diagnosis, establish whether co-
occurring medical, including mental health,
problems exist and allow for the development of
an appropriate and specific treatment plan.10
Assessment tools, as distinguished from
screening tools, are meant to determine the
presence and severity of a clinical condition and
should parallel, at least in part, established
diagnostic criteria for the disease.1 Assessments
tools also might examine social, family and
personal factors that might relate to or co-occur
with substance use. 1 1 This information can help
health care practitioners determine the most
appropriate intervention for their patients.
A comprehensive assessment helps to create the
foundation for effective treatment that is
individualized and tailored to the patient.5 12
The assessment should gather information about
many aspects of the individual including the
physiological, behavioral, psychological and
social factors that contribute to the patient's
substance use and that might influence the
treatment process.13 For example, in addition to
determining the patient's health status, the stage
and severity of the disease14 and the family
history of addiction, the assessment should
determine personality traits such as
temperament; family and social dynamics; the
extent and quality of the patient's family and
social support networks; prior treatment
attendance and response to previous treatment
experiences;15 and the patient's motivation and
commitment to disease management.
Assessments also should cover the situations and
behaviors that may increase risk for relapse and
those that protect against relapse.16 It is
important that assessment instruments also offer
some degree of cultural sensitivity and that they
are age and gender appropriate.17
' See Appendix H for some examples of assessment
instruments used by practitioners and researchers to
help make these diagnoses.
* This, however, is not always the case in commonly-
used assessment instruments (see Appendix H).
§ Much of the research on comprehensive
assessments relates to addiction involving alcohol.
The bottom line is that addiction is an illness that
we are able to treat and manage, if not cure,
provided that we focus on the person with the
addiction, the family and the community— a
holistic approach to a sprawling problem*
-Harold S. Koplewicz, MD
Child and Adolescent Psychiatrist
President
Child Mind Institute
Assessment
Once a patient has been screened for risky use
and identified as requiring professional services
beyond a brief intervention, a physician-
working with other health professionals-should
perform a comprehensive assessment of the
patient's medical, psychological and substance
use history and current health status, present
symptoms of addiction, potential withdrawal
syndrome and related addictive behaviors. This
thorough assessment is a necessary precursor to
treatment initiation and must involve a trained
physician.9 The assessment should utilize
reliable and valid interview-based instruments
and biological tests as needed. The goals of the
assessment are to help the provider determine
the nature, stage and extent of the disease and
whether the patient meets clinical criteria for an
Despite the distinction between screening and
assessment tools, the term screening often is used to
subsume the concept of assessment or
interchangeably with the term in the clinical and
research literatures. Furthermore, while there is some
overlap between screening or assessment procedures
used to identify risky substance use and methods
used to diagnose a clinical addiction, a formal
diagnosis of addiction should be based on the
demonstration of specific symptoms included in the
most recent versions of the Diagnostic and Statistical
Manual of Mental Disorders (DSM) or the
International Statistical Classification of Diseases
(see Chapter II).
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The comprehensive assessment should result in
a treatment plan that is developed in concert
with the patient by a physician with input from
other health professionals. The treatment plan
should articulate clearly the treatment goals and
particular interventions aimed at meeting each of
those goals. The plan should be monitored and
revised as needed should the patient's status or
needs change.18
The comprehensive assessment also should
result in a detailed and thorough written report,
which should be incorporated into the patient's
health record, that:
• Provides a clinical diagnosis and identifies
the particular manifestations and severity of
the disease;
• Identifies factors that contribute to or are
related to the disease;
• Identifies a treatment plan to address these
risk factors and ensure that the treatment
plan is implemented and monitored
effectively; and
• Provides connections to specialty care— i.e.,
an addiction physician specialist or other
specialty providers-as needed and to
auxiliary and support services.19
Stabilization*
The first step in addressing addiction involving
nicotine, alcohol or other drugs is cessation of
use and, if necessary, medically managing the
clearance of toxic substances from the patient's
system via a clinical process often referred to as
detoxification. Detoxification itself addresses
intoxication or withdrawal but is not treatment
of addiction.20 In most cases, cessation of use is
the necessary first step to formal treatment
protocols. While cessation of use can in some
Note that some of the medications described for use
in the stabilization (tobacco cessation and
alcohol/other drug detoxification) process will be
described in greater detail later in this chapter in the
discussions of acute treatments for addiction and
chronic disease management.
cases be a self-managed process, patients
typically need professional assistance.
Cessation of Use
Tobacco. Smoking cessation, while unpleasant
for most persons going through it, is not unsafe
and does not require medical monitoring.
Patients undergoing smoking cessation may
experience certain withdrawal symptoms
including cravings, irritability, impatience,
hostility, anxiety, depressed mood, difficulty
concentrating, decreased heart rate, increased
appetite and sleep disturbances.21 The calming
effect many smokers feel when smoking usually
is associated more with the relief of nicotine
withdrawal symptoms than with the effects of
the nicotine itself. Withdrawal symptoms can
commence in as little as a few hours after the
last dose of nicotine, peak within a few days,
and either subside within several weeks or, in
some cases, persist for months.22
Nicotine replacement therapy (NRT)-through
the use of nicotine patches, gum, nasal spray,
inhalers, lozenges and sub-lingual tablets-is a
common pharmaceutical aid for persons
attempting smoking cessation. NRT lessens
withdrawal symptoms, increasing the chance
that a smoker will quit successfully.23 NRT
replaces some of the nicotine formerly obtained
by smoking.24 However, the nicotine in NRT is
delivered more slowly and at lower dose levels
than through smoking, so NRT is more likely to
reduce cravings than wholly eliminate them.25
Some NRTs mimic the sensations of smoking
(the inhaler) or otherwise occupy the mouth
(gum, lozenges and sub-lingual tablets).26
Research indicates that the most effective use of
NRT involves replicating the experience of
smokers: using nicotine patches to maintain a
baseline serum nicotine level along with the gum
or lozenges to produce a boost of serum nicotine
levels periodically.27
Other pharmaceutical therapies such as
antidepressants (bupropion SR) and nicotine
agonists (varenicline) can help people quit
-88-
smoking and maintain their abstinence.
Alcohol and Other Drugs. Some patients with
addiction involving alcohol and other drugs can
reduce and ultimately cease substance use
without medical supervision, particularly if they
are not physically dependent on the substances
involved, the disease is not advanced and they
have sufficient personal supports to help them
through the cessation process.
Detoxification
For patients who demonstrate physical
dependence on a substance, cessation of use on
their own may be unsafe and medically
supervised detoxification may be required to
manage withdrawal symptoms and
complications.29
Detoxification occurs when toxic substances that
come from the ingestion of alcohol or other
drugs are removed from the body via
metabolism through the liver and excretion
through the kidneys.30 Medically-assisted
detoxification aims to reduce the risk of
discomfort and potential physical harm for
patients who are experiencing withdrawal.31
The detoxification process often requires the
assistance of medical professionals and may
involve the use of pharmaceutical therapies to
guide people safely through withdrawal.
Medical professionals may collaborate with
supportive, non-medical personnel or with
medical personnel in other health facilities to
facilitate the withdrawal process.32
Detoxification is an important and often
necessary prerequisite to effective acute
addiction treatment.33 It should serve as the
catalyst for entry into the treatment system but
does not itself constitute treatment.34
There are three main components to effective
detoxification:
These medications are described in more detail later
in the chapter.
' Physical dependence is characterized by symptoms
of tolerance and/or withdrawal (see Chapter II).
1 . Evaluation. Examine the patient and
determine if symptoms are acutely present-
ideally using standardized instruments to
measure the severity of withdrawal 35— and
documenting vital signs and other physical
manifestations of withdrawal. Assess for
the presence of co-occurring medical and
mental health conditions and determine,
through the use of drug testing, which
substances are present in the person's body
or were used recently.36
2. Stabilization. Assist patients through
withdrawal to re-establish a state of
physiological stability with or without the
use of medications.37
3. Facilitation of Treatment Entry. Provide or
connect patients to addiction treatment and a
continuing care plan.38
Alcohol Detoxification. In alcohol
detoxification services, the cessation of alcohol
ingestion in an alcohol-tolerant individual is
coupled with certain medications to help prevent
the dangerous effects that may accompany
alcohol withdrawal. Withdrawal from alcohol
typically takes up to seven to 10 days, but with
medical management, stabilization can be
achieved sooner. § 39 During the first six to 48
hours of withdrawal from alcohol, symptoms
may include anxiety, nausea, agitation and
difficulty concentrating.40 More severe
symptoms can include hallucinations and
seizures.41 Alcohol withdrawal delirium, also
known as delirium tremens (DTs), is the most
severe and dangerous withdrawal symptom and
usually appears two to four days after the last
drink.42 Some symptoms of alcohol withdrawal,
including DTs and seizures, can be life-
1 These include the Clinical Institute Withdrawal
Assessment-Alcohol Revised (CIWA-Ar), the
Clinical Opiate Withdrawal Scale (COWS) and the
Finnegan Neonatal Abstinence Score.
§ The duration of detoxification varies with the
severity of addiction and some withdrawal
symptoms, such as sleep disturbances, may persist for
several weeks.
-89-
threatening. These withdrawal symptoms can
be more severe in persons who have undergone
prior multiple episodes of alcohol withdrawal, a
process known as the kindling effect. ' 44
Benzodiazepines, which have calming, sedating
effects, have been shown to prevent the onset of
certain alcohol withdrawal symptoms and
acutely relieve such symptoms including
alcohol-induced seizures and DTs.45 A large
review study found that whereas
benzodiazepines are more effective than
placebos at treating seizures in patients going
through alcohol withdrawal, there is no evidence
that they are more effective than other
medications used to treat alcohol withdrawal
syndrome or that particular benzodiazepines are
more effective than others.46 Benzodiazepines
commonly used to treat the anxiety and agitation
symptoms associated with alcohol withdrawal
include diazepam,1 47 chlordiazepoxide,48
lorazepam and oxazepam.49
Because the combined effects of
benzodiazepines and alcohol can be life
threatening or even fatal,50 patients must be
advised not to drink while on benzodiazepine
medications. This is particularly important since
benzodiazepines commonly are prescribed for
alcohol withdrawal on an outpatient basis where
patients' drinking may not be monitored
adequately.51 Another cautionary note is that
benzodiazepines have addictive potential in their
own right; therefore, their use must be
monitored carefully.52
Carbamazepine, an anti-seizure medication, may
be an effective alternative to benzodiazepine
medications for treating alcohol withdrawal.53
Carbamazepine also may be effective at
Although DTs occur only in about five percent of
patients undergoing detoxification, mortality from
DTs historically has been as high as 18.5 percent.
Swift detection and proper treatment can lower this to
about five percent.
' Kindling is the increase in neuronal responses
produced by repeated stimulation. Kindling leads to
a worsening of withdrawal symptoms with each
attempt at alcohol detoxification.
* Diazepam also may relieve muscle spasms and
seizures associated with alcohol withdrawal.
addressing alcohol cravings. The medication's
ability to treat seizures, the minimal potential for
misuse, the significant potential to treat mood
disorder and the lack of sedating effects are
some of its advantages.55
Opioid Detoxification. For patients with
addiction involving illicit or prescription
opioids, including heroin, hydrocodone or
oxycodone, withdrawal symptoms are not life
threatening, but they can be extremely
uncomfortable56 and must be managed
effectively to prevent relapse.57 Opioid
withdrawal symptoms can include abdominal
pain, muscle aches, agitation, diarrhea, dilated
pupils, insomnia, nausea, runny nose, sweating
and vomiting.58 Withdrawal symptoms
generally last from seven days to several
weeks.59 Because medical complications can
develop, patients must undergo regular
monitoring including physical examinations, a
complete review of the functioning of the body's
organs and psychological status and, when
necessary, laboratory evaluations.60
The goal of medical detoxification is a safe,
comfortable and complete withdrawal from
opioids. Abrupt discontinuation of opioids,
especially for a patient who has developed
physical dependence on the drug, typically is not
recommended; instead, in the case of such
dependence involving prescription opioids, the
patient is tapered or weaned off the opioid
medication.5 61 However, for addiction
involving illicit opioids, it is not legal to
prescribe a tapering dose of the illicit drug so
another method must be used.
An alternative to tapering is management of
withdrawal symptoms using non-opioid
medications-such as clonidine62-to decrease the
agitation and discomfort associated with opioid
withdrawal, or other medications that can relieve
the symptoms of acute withdrawal such as
nonsteroidal anti-inflammatory drugs (NSAIDs)
to treat muscle pain, antiemetics for nausea and
non-addicting sleeping medications such as
The use of a tapering dose calculator can help in
this process and can be accessed online at:
www.agencymeddirectors.wa.gov/guidelines.asp
-90-
trazadone to treat insomnia. Detoxification
also can be achieved using specific medically-
prescribed opioids that have less potential for
misuse (methadone or buprenorphine) and then
tapering the patient off these medications when
possible.64
The prescription of methadone for addiction
treatment is restricted by federal regulations;* it
only can be prescribed for detoxification from
opioids in licensed facilities. ' 65 Buprenorphine
can be dispensed or prescribed for illicit or
prescription opioid withdrawal in any outpatient
setting by qualified physicians who have the
required waiver from the Drug Enforcement
Administration (DEA).* 66 While use of these
medically-prescribed opioids can result in
physical dependence, they are considered less
dangerous because they have less potential for
misuse and addiction than other opioids;5 67 they
also are prescribed to patients by a licensed
physician in a medical care setting. They work
by occupying the opioid receptors in the brain,
blocking or minimizing the effects of more
addicting opioid drugs; therefore, a patient on
methadone or buprenorphine maintenance
largely is protected from inadvertent overdose.68
CNS** Stimulant Detoxification. Cessation of
CNS stimulant (cocaine, amphetamine) use may
result in withdrawal symptoms if the user
It is not restricted when prescribed for pain
management.
1 Unless a patient has been hospitalized for another
medical condition.
* Becoming qualified to prescribe and distribute
buprenorphine involves an eight-hour approved
program in treating addiction involving opioids, an
agreement that the physician/medical practice will
not treat more than 30 patients for addiction
involving opioids with buprenorphine at any one time
within the first year and up to 100 thereafter, and
assurance that the trained physician will refer patients
to necessary supplemental psychosocial services.
Physicians who meet the qualifications are issued a
waiver by the Substance Abuse and Mental Health
Services Administration (SAMHSA) and a special
identification number by the DEA.
§ Methadone and buprenorphine also are used for
stabilization and maintenance of addiction involving
opioids.
** Central Nervous System.
develops addiction involving these drugs; these
symptoms are not life-threatening and generally
are less severe than those associated with
withdrawal from alcohol or opioids/ r 69
Symptoms of stimulant withdrawal commonly
include decreased energy, insomnia, agitation,
increased appetite, depressed mood, anxiety and
drug craving.70
Evidence for the effectiveness of pharmaceutical
detoxification to assist in stimulant withdrawal
is limited.7 A vaccine to treat addiction
involving cocaine and ease withdrawal
symptoms currently is being tested. tt 72 But
more research is needed to determine the
vaccine's place in the cocaine detoxification
process and how it can be implemented safely.73
Although there are no available medications
proven to be effective in mitigating the
symptoms of amphetamine withdrawal,74 several
medications currently being researched may
prove useful in alleviating the symptoms. §§ 75
CNS Depressant Detoxification. Withdrawal
from CNS depressants may produce
complications and, in some circumstances, can
be life-threatening.76 Symptoms of withdrawal
from certain prescription CNS depressants, such
as benzodiazepines, are similar to those for
alcohol withdrawal, with seizures and delirium
being the most serious. In the elderly, there is a
risk of falls and myocardial infarctions during
benzodiazepine withdrawal.77 Benzodiazepine
withdrawal symptoms more specifically include
seizure, hypersensitivity, impaired perception of
movement, nausea and tension. It is
common for people detoxifying from
1 During withdrawal from stimulants, there is a risk
of depression or negative thoughts and feelings that
may lead to suicidal thoughts or attempts.
** See page 98 for a discussion of vaccines under
development for addiction treatment.
§§ Drugs under investigation for this purpose include
modafinil, propranolol and bupropion; these
investigations are of off-label uses of approved drugs.
Symptoms of withdrawal from benzodiazepines
often mimic the conditions for which those drugs
initially were prescribed-mood and anxiety
disorders. As such, it sometimes is unclear if the
patient is presenting with withdrawal symptoms or
with symptoms of the underlying condition.
-91-
benzodiazepines to experience significant
withdrawal symptoms lasting between 10 and 14
days,79 and symptoms can persist for four to six
months.80 Therefore, it is recommended that
benzodiazepine detoxification extend over a
period of weeks or months-tapering the patient
off the drugs over time. Another option for
detoxification from benzodiazepines is to
prescribe a different drug from the class, one
with a longer half-life, such as
chlorodiazepoxide or clonazepam.81
Detoxification Venues. Detoxification can take
place in a variety of settings including the
patient's home (monitored and managed by
trained clinicians), physicians' offices, non-
hospital addiction or mental health treatment
facilities, urgent care centers and emergency
departments, intensive outpatient and partial
hospitalization programs and acute care inpatient
* 82
settings.
For planned, monitored or medically-assisted
detoxification, health-care providers, considering
the specific needs of the patient, typically
determine the venue for detoxification. Patients
should be placed in the least restrictive setting
possible.83 Beginning in the 1970s, there was a
movement toward medical ambulatory
detoxification, primarily for alcohol, that
maintained high safety and efficacy profiles while
being more cost effective than inpatient
detoxification. Ambulatory care was intended to
supplement rather than replace inpatient medical
detoxification with the understanding that there
were some people for whom inpatient care still
was necessary. The ability to continue to meet life
responsibilities as well as relatively lower costs
are advantages of outpatient detoxification.84
The primary substance involved in the addiction,
the severity of the symptoms and particular
patient characteristics (e.g., age, co-occurring
substance use and other health conditions) all
play important roles in determining the
appropriate venue for detoxification. For
Such as acute care general hospitals, acute care
addiction treatment units within those hospitals, acute
care psychiatric hospitals and other specialty
hospitals licensed to provide addiction treatment.
example, patients with a history of severe
withdrawals or multiple withdrawals should not
be placed in nonmedical settings for
detoxification.85 For patients deemed a danger
to themselves or others, medically-managed
intensive inpatient treatment or emergency
hospitalization in a psychiatric facility is
recommended.86 For patients with mild or
moderate withdrawal symptoms, outpatient
detoxification can be just as effective as
inpatient, provided the patients have a positive
and helpful social support network.87
Acute Care
Effective, clinical treatments for addiction
include a significant and growing range of
pharmaceutical and/or psychosocial therapies
delivered by qualified health professionals. Due
to the complex nature of addiction and its
physiological, psychological and environmental
risk factors, a multi-pronged approach to its
treatment that includes a combination of
pharmaceutical and psychosocial therapies
typically yields the best results.88 Because of the
extent to which addiction co-occurs with a broad
range of other health problems, effective
medically-managed acute treatment protocols
also should address both co-occurring disorders
and patients' nutrition and exercise
on
requirements.
Guidelines set forth by the American Society of
Addiction Medicine's (ASAM) patient
placement criteria increasingly are being used by
treatment programs, government programs,
managed care companies and other
organizations to appropriately match patient
needs to specific treatment services and to
determine the appropriate level of care.90
Pharmaceutical Therapies
As with most medical conditions,
pharmaceutical therapies can be an important
component of addiction treatment,91 particularly
for patients who are highly motivated to adhere
to the medication regimen.' 92 (Table 5.1)
1 For less motivated patients, supervised
administration of the medication may be necessary.
-92-
Table 5.1
Food and Drug Administration (FDA) Approved and Promising Pharmaceutical Therapies and
the Types of Substances They Address
Type of Medication" 93
Addiction
Addiction
Addiction
Addiction
Addiction
Involving
Alcohol
Involving
Nicotine
Involving
Cocaine
Involving
Opioids
Involving
Marijuana
Reduce Craving/
Withdrawal Symptoms
Acamprosate (Campral)
L X
Bupropion (Zyban,
Wellbutrin)
X
Nortriptyline (Pamelor,
Aventyl)
X*
Clonidine (Catapres)
X*
Baclofen (Kemstro,
Lioresal, Gablofen)
X*
Ondansetron (Zofran)
X*
X*
Gabapentin (Fanatrex,
Gabarone, Gralise,
X*
Neurontin)
Reward Reduction ]
Disulfiram (Antabuse)
X
Naltrexone (Re Via,
Depade, Vivitrol)
X
X
Varenicline (Chantix)
X
Modafinil (Provigil,
X*
Alertec, Modavigil)
Topiramate (Topamax)
X*
X*
Vaccines
X*
X*
Maintenance/Medication-
Assisted Therapies
Nicotine Replacement
Therapy (NRT)
X
Methadone
X
Buprenorphine/Naloxone
(Subutex, Suboxone)
X
Oral Tetrahydrocannabinol
(THC)
X*
a Some of these medications are FDA-approved for treating addiction involving the particular substance, while
others are not. Specifically, the X indicates the type of substance for which the medication has demonstrated
efficacy and has received FDA-approval for use in the treatment of addiction involving the noted substance. The
X* notation indicates that ongoing research is demonstrating promising clinical utility for the medication or
research already has demonstrated clinical utility for the medication in treating addiction involving the noted
substance, but these medications are not (yet) approved by the FDA for use as a pharmaceutical treatment for
addiction involving that particular substance. Medications that have been approved by the FDA for other purposes
can be prescribed off- label (for uses other than that for which it received FDA approval) based on clinical
evidence. However, in spite of clinical evidence of efficacy, these medications may never receive FDA approval
since adding new indications to a medication's FDA-approved label would necessitate significant investments in
FDA-required studies.94
-93-
Pharmaceutical agents for addiction treatment
may work via one of the following mechanisms
of action or by a combination of these
mechanisms:
• Reducing cravings for the addictive
substance and/or reducing aversive
withdrawal symptoms;
• Creating an aversion to the addictive
substance or attenuating the rewarding
effects of the addictive substance, eventually
limiting its appeal; or
• Producing moderated effects resembling
those of the addictive substance and serving
as a less addicting replacement for the
substance of addiction.
Differences in the factors that contribute to
addiction and that determine how the disease
will manifest itself require different and tailored
approaches to treatment, particularly with regard
to pharmaceutical treatments. For example,
individuals with addiction involving alcohol
who drink primarily for the rewarding effects
may be quite different biologically from those
who drink primarily as a means of relieving
stress or reducing negative feelings; as such, the
efficacy of a specific pharmaceutical treatment
may depend on whether it addresses the reward
experienced from using the addictive substance
or whether it serves as a safer medication for
providing relief from negative feelings.96
Likewise, certain genetic or biological
characteristics may determine how effective a
certain type of pharmaceutical intervention will
be for an individual with addiction; for example,
naltrexone has been found to be a more effective
medication for the treatment of addiction
For ease of presentation, a medication is categorized
in this discussion based on its primary mechanism of
action.
* In individuals with a significant genetic
susceptibility, progression from use to addiction is
relatively quick and severe, whereas in individuals
with a low genetic susceptibility, progression from
use to addiction will result from prolonged exposure
to addictive substances and considerable
environmental risk factors, such as stress. (See
Chapter II.)
involving alcohol in patients with a family
history of the disease than in those without a
family history.97 A true understanding of these
differences is in its infancy, but appears to be a
critical factor in tailoring pharmaceutical
treatments to achieve the maximum therapeutic
benefit.98
Medications that Reduce Craving and/or
Withdrawal Symptoms. A number of
medications work on the brain chemicals and
pathways of individuals with addiction to reduce
cravings for the addictive substance and in some
cases reduce symptoms of withdrawal from the
substance.
Acamprosate (brand name Campral), approved
by the Food and Drug Administration (FDA) in
2004 to treat addiction involving alcohol, helps
to normalize brain activity and function that has
been disrupted by heavy alcohol use99 and
reduce withdrawal symptoms such as anxiety
and insomnia.100 It is prescribed for treatment
patients who have discontinued their use of
alcohol.101
Studies regarding the effectiveness of
acamprosate have been mixed in the U.S., but
more consistently positive in Europe.1 102
Several large-scale, controlled studies have
found that acamprosate can double the
abstinence rate among treatment patients at one
to two years following program completion
compared to patients who receive placebos, and
1 The differences in effectiveness findings appear to
be due to methodological differences.
What we hope to do is to actually have a menu
of treatments that clinicians could choose from.
If one drug doesn't work or they can't tolerate
it, " patients would "try another one and so
forth, and hopefully they '11 find one that is
effective.
-Raye Z. Litten, PhD
Associate Director
Division of Treatment and Recovery Research
National Institute on Alcohol Abuse
and Alcoholism (NIAAA)
-94-
is associated with better treatment retention
rates.103 Acamprosate generally is safe to use, as
it does not appear to have a potential for
addiction, has virtually no overdose risk, has
mostly mild side effects and does not interact
significantly with other medications.104
Antidepressant medications also have proven to
be effective in smoking cessation. The
mechanism driving the efficacy of
antidepressants as cessation agents is not yet
fully understood. It may be that antidepressant
medications compensate for nicotine's anti-
depressive effects during withdrawal, lessening
this withdrawal symptom. Alternatively,
antidepressant medications may work-
independent of their antidepressant qualities—on
the neural pathways or the nicotine receptors
that are active in addiction involving nicotine.*
105
• Bupropion sustained release (SR) (brand
names Zyban and Wellbutrin) is a
prescription antidepressant medication that
can be used alone or in combination with
nicotine replacement therapy (NRT) for
smoking cessation.105 It is believed to work
by minimizing cravings and withdrawal
symptoms during the early stages of tobacco
cessation.107 Bupropion may be effective in
relieving negative mood and feelings that
smokers may experience when going
through smoking cessation.108 The
neurological effects of bupropion that aid in
its efficacy as a cessation medication may
include blocking the re-uptake of two
neurotransmitters that are active in addiction
involving nicotine— dopamine and
norepinephrine— and blocking nicotine
receptors.109 The medication reduces the
severity of nicotine withdrawal and the
depression that may accompany smoking
cessation.110 Another advantage of
bupropion for smoking cessation is that it
tends to lessen the weight gain that often
accompanies— and derails-smoking
cessation attempts.111
For example, by blocking nicotine receptors in the
brain.
Patients generally are advised to begin daily
bupropion treatment one to two weeks prior
to quitting so that adequate blood levels of
the medication can be reached.112 The
standard course of treatment is seven to 12
weeks, although this period can be extended
for up to six months if necessary.113
Possible side effects include insomnia, dry
mouth, nausea and a small risk of
seizures.114 Bupropion SR carries a black
box warning' of increased suicidal
tendencies among children, adolescents and
young adults.115
A meta-analysis of 24 bupropion studies
found that the drug can nearly double
smokers' chances of achieving abstinence
lasting longer than five months compared to
a placebo.116 Other analyses found similar
results.117 The efficacy of the drug does not
seem to be sensitive to longer follow-up
periods (up to 12 months), treatment setting,
dosage or the level of supplementary
psychosocial therapy.118
Bupropion also may be a promising
treatment for methamphetamine addiction; it
appears to reduce cravings and the
rewarding effects of methamphetamine.119
However, evidence supporting its ability to
increase abstinence rates is mixed and
further research is needed to establish
bupropion as an effective treatment for
methamphetamine addiction.120
• Preliminary research indicates that another
antidepressant, nortriptyline (brand names
Pamelor and Aventyl), may be an effective
smoking cessation aid.121 Nortriptyline has
been found to double patients' chances of
cessation compared to placebos.122
However, the medication has not yet been
approved by the FDA for use as a smoking
cessation aid; therefore, it only is
recommended for use by patients who have
not responded well to NRT or bupropion.123
' A black box warning from the FDA denotes the
most serious warning of adverse effects for a
medication.
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Clonidine (brand name Catapres), a medication
normally used to lower blood pressure, may
reduce withdrawal symptoms and assist in
smoking cessation.124 However, the many side
effects associated with clonidine suggests that it
only be prescribed to patients seeking to quit
smoking if they are unwilling or unable to use
other first-line cessation medications.125
Baclofen (brand names Kemstro, Lioresal and
Gablofen), a medication normally used to treat
spasticity, has been found to reduce cravings and
withdrawal symptoms in patients with addiction
involving alcohol, helping them to reduce their
drinking and to achieve and maintain abstinence;
however, the existing evidence is too limited to
recommend baclofen for addiction involving
alcohol.126 A double-blind placebo-controlled
study in humans found that more baclofen
patients than placebo patients achieved and
maintained abstinence (70.0 percent vs. 21.1
percent); baclofen patients also demonstrated a
larger reduction in average number of drinks,
alcohol craving, relapse rates and anxiety levels
relative to placebo patients in this study.127
There appears to be a dose-response relationship
for baclofen, with greater effectiveness at higher
doses.128
Ondansetron (brand name Zofran), an anti-
nausea drug,129 has been shown to be effective in
reducing alcohol use cravings and alcohol use
among patients with addiction involving alcohol,
particularly among those with an early onset
addiction.130 The drug may be more effective in
patients with specific genotypes. ' 131 There also
is emerging evidence that ondansetron might be
effective in treating withdrawal symptoms in
patients with addiction involving opioids.132
Gabapentin (brand names Fanatrex, Gabarone,
Gralise, Neurontin), a medication used to treat
neuropathic pain and epileptic seizures, has been
found to reduce withdrawal symptoms and the
Sample size of 39.
' Specifically, those with the L/L genotype of the
5HTTLPR polymorphism. "L" signifies long alleles
and "S" signifies short alleles. Possible genotypes
are L/L, S/S and S/L.
use of marijuana in patients with addiction
involving cannabis.133
Reward Reduction Medications. Certain
medications work to reduce the rewarding or
pleasurable effects of addictive substances, over
time decreasing their appeal.
Disulfiram (brand name Antabuse), approved by
the FDA in 1949 to treat addiction involving
alcohol, works by producing unpleasant
physiological effects in individuals who
consume alcohol; these aversive reactions serve
as a deterrent to alcohol consumption among
those with addiction involving alcohol* 134
For addiction involving alcohol, disulfiram
blocks the production of the enzyme aldehyde
dehydrogenase which enables the liver to
metabolize alcohol.135 The obstruction of this
process leads to a build up of acetaldehyde§ in
the system, causing hangover-like symptoms-
nausea, vomiting, flushing, rapid heart rate-
shortly after alcohol consumption.136 The
medication has not been found to reduce
cravings; its preventive qualities come from
replacing the pleasurable effects of alcohol with
unpleasant effects.137
Although disulfiram is one of the oldest
pharmaceutical treatments for addiction
involving alcohol, there are few scientifically
valid studies of its efficacy.138 The medication
appears to be most effective when its use is
supervised to assure compliance.139 Researchers
suggest that the relatively limited evidence of
the efficacy of the drug may be linked to low
adherence rates: in one study only 20 percent of
participants who completed the trial complied
with disulfiram treatment. Among patients who
completed the trial, those who received a
* Disulfiram is the most commonly-used aversion
medication for the treatment of addiction involving
alcohol. Another example of a medication that
produces a similar aversive effect in individuals who
consume alcohol is calcium carbimide (brand name
Temposil); other medications used for non-addiction
clinical purposes, such as cephalosporins which are
used to treat bacterial infections, have side effects
similar to disulfiram when alcohol is consumed.
§ The major metabolite of ethanol.
-96-
standard dose of disulfiram reported
significantly fewer drinking days than their
peers over the course of a year.140 One
explanation for the variation in effectiveness
may be related to addiction severity: those with
more severe addiction may drink despite the
adverse reactions caused by disulfiram, or avoid
taking the medication altogether.141
Naltrexone, used in the treatment of addiction
involving alcohol and opioids, blocks opioid
receptors in the brain, leading to reductions in
the reinforcing effects of these drugs.142 It does
this by disrupting the transmission of dopamine -
-and thus the endorphin rush-caused by alcohol
and opioid ingestion.143
Oral naltrexone (brand names Re Via and
Depade), which is available as a daily tablet,
was approved by the FDA to treat addiction
involving alcohol in 1984. Injectable naltrexone
(brand name Vivitrol), which is an extended
release monthly deep intramuscular gluteal
injection,* 144 was approved by the FDA in 2006
for addiction involving alcohol and in 20 1 0 for
the treatment of addiction involving opioids.145
Naltrexone is prescribed for patients who have
not ingested opioids for seven to 1 0 days
because it can cause serious withdrawal
symptoms if used at the same time as an
opioid.146
Because of naltrexone's mechanism of action —
reducing the reward or "high" associated with
substance use— some patients may not take the
medication regularly. 147 Noncompliance also
may be associated with experiencing
uncomfortable side effects ' at the start of a
course of treatment. 148 Unless participants
adhere to their treatment regimen 70 to 90
percent of the time,1 naltrexone does not
produce significant outcomes.149 Injectable
When injected, the pharmacological agent releases
its active compound in a consistent way over a long
period of time.
1 Side effects can include gastrointestinal problems
such as nausea, vomiting and abdominal pain and
central nervous system-related symptoms such as
headache and fatigue.
* The necessary adherence rate varies by the duration
of treatment.
naltrexone provides two advantages which may
improve retention and success rates: the need
for a monthly injection rather than a daily pill
and the need for regular contact with medical
and other supporting staff in the course of a
clinic visit which is required to obtain the
medication.150 A disadvantage of the injection
formulation, however, is that it has more side
effects at higher doses.151
For addiction involving alcohol, the medication
is more effective at reducing heavy drinking
than increasing abstinence rates.152 Several
randomized, placebo-controlled trials found that
compared to patients taking placebos, patients
taking naltrexone report significantly fewer
drinking days, fewer drinks per drinking day,
reduced cravings and reduced relapse.153
Because naltrexone blocks the euphoric effects
of opioids and does not produce a high when
taken, there is much less potential for misuse or
diversion than there is for other pharmaceutical
treatments, such as methadone, for addiction
involving opioids.154 In one randomized,
controlled study, patients with addiction
involving heroin who received naltrexone
injections were significantly likelier to have
remained in treatment over the course of the
study than patients receiving a placebo
injection.8 155 Buprenorphine,** when added to
naltrexone, has been found to improve retention
in treatment.156 Relapsing to the use of opioids
after beginning naltrexone treatment can
increase patients' risk of overdosing, due to
naltrexone's effect on increasing the sensitivity
of opioid receptors in the brain to the effects of
opioids.157
Varenicline (brand name Chantix) is an effective
therapy for smoking cessation that works by
reducing the rewarding effects of nicotine
among patients who smoke while on the
medication and by reducing the craving and
withdrawal symptoms that occur among
abstinent patients.158
s Naltrexone patients also were less likely than
placebo patients to test positive for cocaine,
benzodiazepine, marijuana and amphetamine use.
** See page 101.
-97-
Research indicates that varenicline use,
compared with a placebo, can significantly
increase a patient's chances of attaining
continual abstinence from smoking over six
months.159 A large-scale analysis of several
randomized controlled trials found that the
medication was significantly more effective than
placebos or bupropion in relieving cravings and
in increasing the likelihood of achieving
continuous abstinence over a 12-month
While nausea is the most commonly-reported
side effect, insomnia, headaches and nightmares
also are prevalent.161 In February 2008— two
years after Chantix was approved-the FDA
released a public health advisory warning
patients that the medication has the potential to
aggravate psychiatric illnesses and in some cases
lead to the development of neuropsychiatric
symptoms, such as anxiety, tension, depression
or suicide attempts.162 This advisory led to
modifications in the product labeling and the
medication guide advising medical professionals
to monitor all patients taking the medication for
neuropsychiatric symptoms.163 More recently,
medical professionals were advised to monitor
use of the medication among patients with
cardiovascular disease since Chantix has been
linked to adverse cardiovascular effects in these
patients.164
Modafinil, a stimulant medication (brand names
Provigil, Alertec and Modavigil), used to treat
narcolepsy and other sleep disorders, reduces the
stimulating effects of cocaine.165 At the same
time, it may reduce cocaine cravings and
withdrawal symptoms.166 In one study, patients*
with addiction involving cocaine who received
daily doses of modafinil for eight weeks
submitted nearly twice as many clean urine
samples than placebo patients during the course
of the study and were more than twice as likely
to achieve at least three weeks of prolonged
abstinence.167 Another study found modafinil to
be effective in reducing cocaine use and cocaine
craving in patients with addiction involving
Who met clinical diagnostic criteria for dependence
and who used at least $200 worth of cocaine during
the prior month.
cocaine who took part in individual
psychosocial therapy.168
Topiramate (brand name Topamax), an
anticonvulsant, has been validated by
randomized controlled trials to treat addiction
involving alcohol.169 It is believed to work by
reducing the release of dopamine and thus the
rewarding effects of alcohol use and the urge to
drink.170 It appears to reduce alcohol withdrawal
symptoms and can be used in patients who are
not yet abstinent from alcohol.171 Topiramate
also is a promising pharmaceutical treatment for
addiction involving cocaine, but additional
research is needed to establish its efficacy.172
Preliminary research suggests that the
anticonvulsant and mood-stabilizing medications
carbamazepine and valproate also may be
effective in treating addiction involving
alcohol.173
Vaccines. Recent research in pharmacotherapy
for substance addiction has examined the use of
vaccines in the treatment process.174 These
vaccines work by producing a sufficient quantity
of antibodies that bind to the substance and
prevent or significantly impede it from entering
the brain,* reducing the accumulation of the
substance in the brain and ultimately decreasing
its rewarding effects.175 Much of the work on
vaccines for addiction is still in the preclinical
phase of development.176
Vaccines for addiction involving nicotine5 are
farthest along in the development phase. They
are proving to be safe, with limited adverse side
effects and have shown promise for helping
smokers quit.177 However, these vaccines still
are undergoing clinical trials to test for safety
and efficacy. While they may be helpful in
reducing the rewarding effects of nicotine in
those who already are addicted, they do not
1 Who did not have co-occurring addiction involving
alcohol.
* Antibodies typically are comprised of larger
molecules than addictive substances, making them
less able to cross into the brain.
§ NicVax, Nic002 (also known as NicotineQB) and
TA-Nic are the vaccines currently under
investigation.
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prevent addiction and should be used in
conjunction with other therapeutic
approaches.178
A cocaine vaccine also has been developed and
was found in a preliminary study to reduce
cocaine use.179 Researchers also are exploring a
vaccine or antibody administrations for other
addictive stimulants including
methamphetamine180 and phencyclidine (PCP)181
and have found promising results in animal
samples.
Maintenance Medications/Medication
Assisted Therapies. Certain medications used
to treat addiction function by delivering a less
dangerous or less addicting version of the
addictive substance during the acute care phase
of addiction treatment. These medications may
function by reducing cravings or withdrawal
symptoms and/or by reducing the rewards
associated with the addictive substance.
Maintenance medications have proven to be
highly effective in treating a variety of
manifestations of addiction and in disease
management.
Nicotine Replacement Therapy (NRT). NRT,
when used as directed, provides lower doses of
nicotine at a slower rate than smoking,182
thereby easing nicotine withdrawal symptoms.183
For many smokers, it works best as an aid to
managing nicotine-related cravings when used in
conjunction with psychosocial therapies. In
most cases of acute care treatment, a therapeutic
level of nicotine is reached and then use is
reduced in order to eliminate the medication
entirely or reach a maintenance level.184
Because most patients who use NRT control
their treatment regimen on their own, there is a
risk that the nicotine intake from NRT products
may be higher than intended for those who do
not use them as directed or who use them while
continuing to smoke.185
Nicotine gum, lozenges and inhalers and nasal
sprays deposit nicotine in the bloodstream
through the lining of the mouth or nose, whereas
These medications also may be used for an
extended period of time for disease management.
the nicotine patch delivers the nicotine through
the skin.186 Nicotine gum and lozenges both are
over-the-counter medications; inhalers and
sprays require prescriptions. The nicotine patch
is available both over-the-counter and by
prescription.
A meta-analysis f of 1 3 studies found that use of
nicotine gum can increase significantly smokers'
chances of quitting for at least six months.188
The use of nicotine lozenges nearly doubles the
chance of achieving continuous abstinence over
at least a six-month period.189 Side effects of
nicotine gum and lozenges include sore throat,
heartburn, jaw pain and nausea.190
Nicotine inhalers come in cartridges which
release nicotine vapor when puffed that is
absorbed through the lining of the mouth and
through the back of the throat.191 Two meta-
analyses found that inhaler use can nearly
double patients' abstinence rate over at least a
six-month period, relative to those who received
a placebo.192 The primary side effect is local
irritation.193 Nicotine nasal spray is aerosolized
nicotine that comes in a spray pump. The
nicotine is sprayed into the nostrils and absorbed
rapidly by the nasal membranes.194 Meta-
analyses indicate that patients almost double
their chances of achieving and maintaining
abstinence at six months with the use of a nasal
spray versus a placebo.195 The primary side
effect of the medication is local irritation.196
This form of NRT has the highest potential for
misuse: 15 to 20 percent of patients report using
the spray for longer than the recommended
period and five percent report using a higher
dose than recommended.197
The nicotine patch is available in both single and
step-down dosages. An eight-week course of
' The review included only those studies that had
been published in peer-reviewed journals; however,
some studies were supported by the pharmaceutical
industry. Most of the studies included in the analysis
drew participants from self-selecting populations of
smokers and, in general, the studies' participants
received counseling regardless of whether they were
randomly assigned to receive medication or placebos.
(This is true of all meta-analyses of tobacco cessation
interventions reported here.)
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treatment is most common; however, one
study found that an extended course of
treatment-24 weeks-improves outcomes.199
Unlike other forms of NRT, patches do not
address the behavior of smoking by occupying
the hands or the mouth or inhaling, but by
passively and slowly delivering the nicotine.200
A meta-analysis of 24 studies found that the use
of nicotine patches for six to 14 weeks can
nearly double a smoker's chance of sustaining
abstinence for at least six months compared to
placebos.201 Unlike nicotine gum, there is little
evidence supporting a connection between
higher doses and higher efficacy rates, or
between longer treatments and better
outcomes.202 The patch also appears to be
effective regardless of additional psychosocial
interventions.203 The primary side effect of the
patch is skin sensitivity and irritation.204
Contrary to the many controlled studies
supporting the efficacy of NRT, a population-
based survey of adult smokers who recently had
quit smoking casts doubt on its effectiveness in
smoking cessation and relapse prevention. In
this study, nearly one-third (30.6 percent) of
smokers who had quit smoking within the
previous two years reported having relapsed,
regardless of whether they used NRT for the
recommended amount of time and regardless of
whether the use of NRT was accompanied by
professional behavioral counseling. While this
study appears to call into question the efficacy
of NRT in achieving smoking cessation in the
general population,205 it actually underscores the
fact that NRT is not a comprehensive treatment
approach to addiction involving nicotine, but
rather an aid to smoking cessation to be used in
conjunction with other evidence-based acute
care and chronic disease management
approaches.
Methadone. Methadone is a synthetic opioid
used as replacement therapy for patients with
addiction involving opioids. Methadone
reduces cravings and withdrawal symptoms by
Methadone can be used in the stabilization, acute
treatment and disease management/maintenance
phases of treatment for patients with addiction
involving opioids.
stimulating opioid receptors in the brain and
reduces the rewarding effects of opioids by
blocking their euphoric effects.207 Although
methadone is an opioid, it does not produce the
same euphoric rush characteristic of heroin or
oxycodone; its effects are slower and steadier.208
Methadone can be taken orally and has a long
half-life with a slow onset of action.209
Methadone is safe when used as directed. It
allows individuals with addiction involving
opioids to function relatively normally.210
Potential side effects of methadone include
drowsiness, weakness, headache and nausea, and
side effects are more likely to occur when
starting methadone, when switching from
another narcotic/opioid medication to
methadone and when the dosage is increased.211
Multiple studies have found that participation in
methadone maintenance treatment (MMT) is
related to significant reductions in patients' use
of opioids, criminal behavior, injection drug use,
needle sharing and risky sexual behavior which
can increase the risk of HIV and sexually-
transmitted diseases;' MMT also is related to
higher treatment retention rates.212
Methadone does, however, carry the potential
for misuse 213 and the risk of overdose.214 While
methadone is effective in inhibiting the effects
of opioids like heroin and morphine, it does not
appear to inhibit the effects of alcohol or other
drugs; rather methadone may magnify the
effects of alcohol and other CNS depressants.215
Its use in concert with other addictive substances
can result in adverse interactions. Methadone
also may accumulate in the body to a toxic level
if it is taken too often, or in larger than
recommended quantities.216 Because of the risk
of methadone misuse and its consequences,
methadone distribution is regulated by strict
federal and state guidelines.217 Methadone
prescribed for addiction involving opioids can
1 Because methadone does not require intravenous
injection, methadone users are less likely to engage in
needle sharing and because they do not need the same
amount of money to obtain heroin, they are less
likely to engage in prostitution compared to their
heroin-using counterparts.
-100-
be obtained only through specially-licensed
* 218
treatment programs.
Buprenorphine. Buprenorphine is used in the
treatment of addiction involving opioids and,
when used as directed, functions both by
reducing craving for addictive opioids and by
easing withdrawal symptoms.219 At low doses,
buprenorphine enables patients with addiction
involving opioids to discontinue their use of the
drugs without experiencing withdrawal
220
symptoms.
There are two forms of the medication:
buprenorphine alone (brand name Subutex) and
a buprenorphine/naloxone combination therapy
(brand name Suboxone).221 Approved in 2002
by the FDA for treating addiction involving
opioids, Subutex generally is prescribed during
acute treatment followed by Suboxone for
maintenance therapy.222 The naloxone
component of Suboxone serves to reduce the
rewarding effects of opioids and helps to prevent
the misuse of the medication which can occur if
Suboxone is crushed and then injected or snorted
to achieve a high.223
Buprenorphine must be administered under the
supervision of a trained physician.224 It can be
prescribed by physicians who are certified in
addiction medicine ' or who complete at least
eight hours of training1' in the treatment and
management of addiction involving opioids.5 225
Once such training is completed, physicians may
submit an application to the Substance Abuse
and Mental Health Services Administration
(SAMHSA) and receive an identification
Such restrictions apply only to the use of methadone
in addiction treatment and not when physicians
prescribe methadone to treat or manage pain.
' Through the American Board of Addiction
Medicine or the American Osteopathic Association.
* Approved training includes training provided by the
American Society of Addiction Medicine, the
American Academy of Addiction Psychiatry, the
American Medical Association, the American
Osteopathic Association, the American Psychiatric
Association or any other organization that the
Secretary of Health determines is appropriate.
§ Physicians also must have the ability to provide or
refer patients to any necessary ancillary services.
number from the DEA allowing them to
prescribe the medication.226
Buprenorphine provides moderate relief from
opioid withdrawal and has less risk of misuse
and overdose than methadone.227 Another
advantage to buprenorphine is that it can be
dosed less frequently than every day and still
have a beneficial effect, which could help to
enhance medication adherence.228 Promising
results are emerging from preliminary research
on low-frequency dosing with sustained-release
formulations of the medication.229 Despite these
advantages, buprenorphine has similar side
effects to methadone and other opioids including
nausea, vomiting and constipation.230
Buprenorphine is equally effective as methadone
in treating addiction involving opioids.231
Research reviews of pharmaceutical treatments
for addiction involving opioids have found that
regardless of the dose, buprenorphine is better
than placebos for ensuring patient retention,232
and that higher doses increase the likelihood of
retention and abstinence relative to lower
doses.233 A randomized, controlled trial found
that patients receiving buprenorphine were
significantly likelier to have negative urinalyses
than placebo patients and to report decreased
cravings for opioid drugs.234
Recent research has begun to explore, using
animal models, the benefits of using
buprenorphine to treat addiction involving
methamphetamine.235
Oral THC. Preliminary research suggests that
oral tetrahydrocannabinol (THC), made from the
psychoactive ingredient contained in cannabis,
may serve to reduce withdrawal symptoms and
cravings in patients with addiction involving
marijuana without producing marijuana-like
intoxication effects.236 However, research on
oral THC and other pharmaceutical therapies for
use in the treatment of patients with addiction
involving marijuana, while promising, is in an
early stage and clinical trials are needed to
support their use in clinical interventions.237
-101-
Psychosocial Therapies
Psychosocial treatments for substance addiction
aim to alter patients' attitudes and behaviors
with regards to the use of tobacco, alcohol and
other drugs. These therapies enhance patients'
skills in coping with life challenges, navigating
high-risk situations, avoiding substance use
triggers, controlling cravings and coping with
lapses.238 Some therapies focus on enhancing
patients' motivations to change their substance-
related behaviors. Other therapies focus on
helping patients alter their environments in order
to reduce pressures and cues to use, or provide
positive or negative reinforcements to help
patients change their attitudes and behavior.239
Psychosocial therapies are critical components
of almost every treatment regimen, regardless of
a patient's primary substance of addiction; when
combined with pharmaceutical treatments they
enhance treatment efficacy.240
As is true of treatments for most other health
conditions, successful treatment for patients with
addiction takes into account patients' social and
financial circumstances as well as their physical
well-being. And, as is the case for other health
conditions, not all approaches work equally well
for all patients; the effectiveness of a particular
approach depends on patient circumstances such
as the severity of the addiction, the primary
substance involved in the addiction, the extent of
social support and the presence of co-occurring
disorders; the venue in which the treatment is
provided; and the nature and dynamics of the
provider-patient relationship.241
The following are brief descriptions of the
primary psychosocial therapies for addiction
treatment:
Motivational Interviewing (MI) and
Motivational-Enhancement Therapy (MET).
Motivational techniques capitalize on patients'
readiness to stop using addictive substances and
enter treatment by bolstering their motivation to
change their substance use behaviors.242 In
acute care, motivational therapies are employed
early in the treatment process. They also may be
used in conjunction with other psychosocial and
pharmaceutical approaches.243
Motivational Interviewing (MI), which can
occur in inpatient or outpatient settings, is rooted
in the idea that individuals with addiction often
feel ambivalent about their substance use and the
need to change their behaviors.244 MI
techniques help patients deal with this
ambivalence and strengthen their commitment to
engage in behavior change.245 Motivational
Enhancement Therapy (MET) is an adaptation
of MI* that restricts the intervention to four
sessions.1 246
Both MI and MET have proven efficacy in
addressing adolescent and adult addiction and
are cost-effective approaches to treating
addiction involving nicotine, alcohol and other
drugs.247 Two main benefits of MI/MET are
increased treatment retention and program
completion,248 which are associated with
improved treatment outcomes.249 A study of
tobacco cessation among patients who had
previously had a heart attack found that those
receiving MI were more likely to achieve
abstinence after a year than patients who only
received brief advice about quitting (65.5
percent vs. 37.0 percent).1 250 An evaluation of
MET across five treatment sites found that it
was associated with greater reductions in alcohol
and other drug use over a 12-week period than
standard individual counseling.5 251
Both modalities are based on the Transtheoretical
Model of Behavior Change.
1 MET was developed for Project MATCH (1997), a
large study of treatment efficacy that compared the
effectiveness of three treatment modalities: 12
sessions of cognitive behavioral therapy (CBT), 12
sessions of Twelve-Step Facilitation Therapy or four
sessions of MET. All three groups showed
significant and comparable declines in alcohol use up
to three years later.
* These rates are based on at least one week of
abstinence corroborated by a family member.
§ More than 450 individuals with addiction were
randomly assigned to receive three sessions either of
MET or standard individual counseling during a one-
month period.
-102-
Motivational Interviewing
The MI therapist attempts to:
FvnrpQQ pmnntViv tlirmio'li rpflpptivp
i^AJJltoo K^lLi^jalLly llllVJllgll 1 1 lltVll V t
listening;
•
Recoonize discrenancies between natients'
goals or values and their current substance
use;
•
Provide normative feedback on the
discrepancy between patients' substance
use and that of their peers;
•
Adjust to patient resistance rather than
oppose it directly;
•
Avoid arguments and direct
confrontations; and
•
Support patients' sense of self-efficacy to
change their behavior.252
Cognitive Behavioral Therapy (CBT).
Cognitive Behavioral Therapy (CBT) involves
training in social skills, self-control and stress
management through activities such as role
playing, behavioral modeling and feedback.253 It
is designed to help patients identify, recognize
and avoid thought processes, behaviors and
situations that are associated with substance use;
manage cravings; refuse offers of tobacco,
alcohol or other drugs; and develop better
problem-solving and coping skills.254
CBT generally is used as a short-term
intervention and can be tailored both to inpatient
and outpatient programs via group or individual
therapy.255 The therapy has been proven
effective for adolescents and adults and for a
variety of manifestations of substance
addiction.256 CBT has demonstrated efficacy for
specific populations such as women with
addiction and individuals with co-occurring
disorders.* 257
Community Reinforcement Approach (CRA).
The Community Reinforcement Approach
(CRA) is a multi-phase, intensive 24-week
outpatient treatment for addiction involving
CBT may work as well for other populations and
other substances, but available data largely are
focused on the ones described here.
alcohol and drugs other than nicotine.
Counseling sessions focus on improving family
relations, learning skills to reduce substance use,
acquiring vocational skills and developing
recreational activities and social networks that
can help to minimize the drive to engage in
substance use.259 CRA also assists patients in
developing communication, problem-solving
and drug refusal skills.260 CRA is based on the
notion that patients must be taught life skills and
shown that living substance free can be more
rewarding than a life of addiction.261
There is evidence of the effectiveness of CRA
for treating patients with addiction involving
alcohol and drugs other than nicotine.262
Effectiveness is enhanced when coupled with
pharmaceutical interventions and abstinence-
based incentive programs, such as the provision
of vouchers exchangeable for retail items
contingent on negative urinalysis results.263
Participation in a CRA intervention also has
shown positive supplementary effects, such as
increased employment rates and decreased
criminal involvement.264
Contingency Management (CM).
Contingency Management (CM) is an
intervention that uses positive and negative
reinforcement to alter behavior, although
rewarding positive behavior has been
demonstrated to be more effective than
punishing negative behavior.265 Most CM
interventions provide patients with vouchers and
incentives for meeting treatment-related goals
such as producing a drug- free urine test.
Incentives can include cash rewards, vouchers to
purchase desired items or treatment-related
privileges such as receiving multiple doses of
medication at one time to avoid having to make
numerous clinic visits.266
The effectiveness of CM has been demonstrated
for addiction involving nicotine, alcohol,
marijuana, cocaine, methamphetamine and
opioids.267 CM can improve program retention,'
increase abstinence and help prevent relapse. It
is most successful when used in conjunction
1 Improved program retention is associated with other
positive treatment outcomes.
-103-
with other interventions, such as the community
reinforcement approach (CRA).* 268
Behavioral Couples/Family Therapy.
Couples- and family-based treatments aim to
improve communication and support and reduce
conflict between couples and within families
that have a member with addiction.269 Since
lack of social and family support often is a
barrier to treatment enrollment, the support of
family members is important in helping
individuals with addiction enter and complete
treatment. Studies have found family and
couples therapy to be effective for adolescents
and adults, men and women and racial/ethnic
minorities as well as for individuals for whom
the primary substances of addiction are alcohol,
marijuana, opioids or cocaine.270
A family approach to treatment generally is
more effective than individual-based programs
and tends to have higher retention rates than
other evidence-based interventions.271
Combining couples/family therapy with other
forms of individual-based treatments, such as
cognitive behavioral therapy (CBT), tends to
increase treatment effectiveness.272
[Addiction] is a family disease and you cannot
treat an addict without bringing in the family
and children.215
-John Schwarzlose
Chief Executive Officer
Betty Ford Center
Combined Therapies
Treatment programs that combine
pharmaceutical and psychosocial treatments
typically are more effective for individuals with
addiction than the use of either form of
intervention alone.273
Stronger effects were found when the voucher was
delivered immediately after the patient met the
contingency requirement and when vouchers were of
a higher value.
Our efforts to date have taught us some
humbling lessons about addictive diseases,
namely, that they are complex biopsychosocial
entities which defy simple "either/or"
solutions.214
-Norman S. Miller, MD
Professor of Medicine and Psychiatry
Michigan State University
Combination therapy is successful for multiple
reasons. First, the provision of one treatment
modality tends to enhance compliance with the
other.276 For example, medication may help
patients better tolerate withdrawal symptoms
that otherwise might have discouraged their
participation in psychosocial therapy and
psychosocial therapy might encourage patients
to initiate and maintain a course of
pharmaceutical therapy.277 Medications used in
conjunction with psychosocial interventions
have been found to increase patients' likelihood
of remaining in treatment and maintaining
abstinence.278 Second, because there is no one
treatment that works perfectly for every patient,
patients who are provided with more than one
treatment approach have an increased chance of
success.279 Third, each modality may produce
different outcomes, increasing overall success.
For instance, in the case of smoking cessation,
pharmaceutical therapy helps patients face
withdrawal symptoms and maintain abstinence,
while psychosocial treatments improve
behavioral, cognitive and coping skills that are
particularly useful for ensuring compliance with
treatment and preventing relapse.280
Addiction Involving Nicotine. The
combination of nicotine replacement therapy
(NRT) and psychosocial approaches to smoking
cessation increases patients' chances of quitting
and their chances of achieving long-term
abstinence.281 A review of combined therapy
studies shows that the inclusion of NRT
produced up to a 15-percentage point increase in
efficacy rates over psychosocial treatment
alone.282 One explanation for the improved
results of combined therapies for tobacco
cessation is that NRT is the primary mechanism
behind patients' initial quitting success while the
psychosocial therapies give patients the tools
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they need to avoid relapse over the longer
term.283 Forms of pharmaceutical therapy other
than NRT, such as antidepressants, also can
enhance the benefits of psychosocial treatment
for smoking cessation.284
Addiction Involving Alcohol. In one study,
patients with addiction involving alcohol who
received daily doses of naltrexone were less
likely than those taking placebos to relapse if
they also participated in psychosocial therapies,
including cognitive behavioral therapy (CBT)
(38 percent vs. 60 percent) or motivational-
enhancement therapy (MET) (44 percent vs. 56
percent) over the course of 12 weeks.* 286
Patients in another study f who received CBT for
a three-month period were likelier to achieve
abstinence by the end of the 12-week program if
they also received daily doses of acamprosate
(38 percent vs. 14 percent).287 Another study
found that six months after treatment
completion, disulfiram patients in a community
reinforcement approach (CRA) program spent
significantly less time drinking than patients
who used only disulfiram (abstinent 28.3 days
vs. 8.0 days that month).288
CBT patients who took naltrexone spent
significantly more of their time in treatment abstinent
from alcohol than any of the other study groups.
' The study groups were not randomized but matched
based on gender, age, previous treatment episodes,
detoxification history and average alcohol intake.
Addiction Involving Other Drugs. With
regard to treatment for addiction involving
opioids, incorporating family therapy into a
treatment regimen that includes naltrexone
therapy enhances treatment outcomes with
regard to medication compliance; abstinence
from opioids and other drugs during treatment
and during a year of follow-up; and measures of
drug-related, legal and family problems at one-
year follow-up.289 A meta-analysis of 30 studies
conducted in outpatient methadone treatment
settings found that the inclusion of contingency
management (CM) is related to fewer positive
urine tests submitted by patients with addiction
involving opioids.290 CM also has been found to
augment naltrexone treatment for addiction
involving opioids by increasing patients'
compliance with their treatment regimen.
Naltrexone patients who received contingency
management in the form of vouchers in
exchange for clean urinalyses, on average,
stayed in treatment longer (7.4 weeks vs. 5.6
weeks), submitted more opioid- free urine
samples (18.9 vs. 13.5) and were abstinent
continuously over longer periods of time (49.1
days vs. 37.7 days) than patients who received
naltrexone without a CM component.291
Another study found that patients on methadone
maintenance treatment who received weekly
community reinforcement approach (CRA)
sessions demonstrated significantly greater
reductions in drug problem severity1 than
patients who received standard methadone
292
maintenance services.
Other research finds that cognitive behavioral
therapy (CBT) patients who received daily
doses§ of modafmil versus a placebo provided
significantly more clean urine tests (42.3 percent
vs. 24.0 percent) and were likelier to achieve
abstinence from cocaine over at least a three-
week period (33 percent vs. 13 percent).293
Addiction Involving Poly-Substances.
Research on the best methods of treating
individuals with addiction involving multiple
substances is limited. One study found that
methadone maintenance patients with addiction
As measured by the Addiction Severity Index.
400 mgs.
A Spectrum of Smoking Cessation
Treatments
Smokers of less than five cigarettes per day
will have a good chance of success in quitting
by choosing a quit date, getting rid of tobacco
and using freely-available counseling/support
services. Smokers of 6-14 cigarettes per day
probably are moderately dependent and will
benefit from an approved smoking cessation
aid (nicotine patch, gum, lozenge, inhaler or
nasal spray, bupropion, varenicline). Smokers
of 15 or more cigarettes per day probably are
highly dependent and will benefit from more
intensive counseling and possibly combination
pharmaceutical therapy.285
-105-
involving both opioids and cocaine fared better
if they were randomly assigned to receive
bupropion versus placebos and CM versus no
psychosocial intervention.294 Other research
points to the potential utility of combining an
antidepressant* with CM for patients with
addiction involving opioids and cocaine who are
maintained on buprenorphine.295 Patients who
received this combined therapy provided more
drug-free urine samples during treatment and
achieved a period of continuous abstinence that
was, on average, twice as long as patients with
addiction involving opioids and cocaine who
were in the control conditions. f 296 Preliminary
evidence also suggests that daily doses of
naltrexone1 combined with CBT may be
effective for treating addiction involving alcohol
and cocaine, particularly among men.297
Nutrition and Exercise
A healthy nutrition and exercise regimen can
mitigate the symptoms of withdrawal, enhance
the effects of evidence-based treatment and help
sustain successful treatment outcomes.298
Furthermore, because different addictive
behaviors can share common causes, patients in
treatment for addiction involving nicotine,
alcohol or other drugs may substitute unhealthy
foods in an attempt to satisfy addictive
cravings.299 This is particularly evident in the
common case of weight gain following smoking
cessation. As such, a comprehensive approach
to addiction treatment includes interventions
aimed at ensuring good nutrition and exercise.
Nicotine, alcohol and other drug use also disrupt
normal body functioning— resulting in nutritional
deficiencies, dehydration or electrolyte
imbalance-and often lead to unhealthy lifestyle
changes such as poor diet and irregular eating
habits.300 Providing patients in addiction
treatment with nutritional programming may
help them to reverse some of the damage that
smoking, drinking and using other drugs can
inflict on their bodies. The improvements in
desipramine
' Who took placebos combined with CM,
desipramine without CM or placebos without CM.
* 150 mg.
general health and mood that may result from
healthy eating habits also could help patients
maintain their abstinence.301
Some individuals in treatment attempt to
compensate for the lack of alcohol, for example,
by consuming significant amounts of sugar and
other carbohydrates which may increase
serotonin5 levels.302 A healthier approach,
according to one theory, suggests that eating
foods that are rich in the precursors of the
neurotransmitters which are depleted when a
substance user abstains will reduce cravings for
those substances and facilitate the treatment
process.303 These include protein-rich foods
such as meat, fish, dairy products and nuts.304
Exercise also stimulates brain cells that reinforce
dopamine -related reward pathways.305 This
reinforcement may allow substance users to
experience pleasurable effects from exercise
which potentially could reduce their substance-
related cravings.306 Exercise generally is
beneficial in reducing symptoms of depression
and anxiety that often co-occur with and
contribute to addiction.307 Another theory
regarding the utility of exercise in a
comprehensive treatment program is that as
individuals develop a mastery of exercise
techniques, they increase their self-efficacy—the
belief that one can master new skills— which can
be applied to disease management strategies.308
Patients who exercise in group settings also may
benefit from social support networks and social
interactions that do not involve tobacco, alcohol
or other drug use.309
Exercise moderates the effects of nicotine
withdrawal symptoms including reductions in
cravings, negative mood,310 sleep disturbances311
and tension.312 One study found that exercisers
in a smoking cessation program were twice as
likely as those who did not exercise to
demonstrate continual abstinence by the end of
the three-month program, and three and 12
months following treatment completion. After a
year, exercise participants were 36 percent less
5 A neurotransmitter involved in mood, emotion,
sleep, appetite and some aspects of addiction.
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likely than those who did not exercise to have
relapsed.313
Chronic Disease Management
Although the reasons are not yet clear, some
individuals may experience one episode in
which their symptoms meet clinical diagnostic
criteria for addiction and be non-symptomatic
thereafter.314 In many cases, however, addiction
manifests as a chronic disease-a persistent or
long-lasting illness— which requires ongoing
professional treatment and management.315 This
may be due to a preexisting brain dysfunction or
to changes that occur in the brain in response to
repeated exposure to addictive substances which
increase the vulnerability of the individual to
relapse, even after cessation of substance use.316
All chronic diseases— regardless of whether they
are genetically based, driven by biological or
environmental influences or originate from some
combination of these factors-require long term,
evidence-based medical management of the
disease by qualified health professionals and
may include pharmaceutical and/or psychosocial
therapies as indicated, to assure that patients
remain symptom free and that co-occurring
health conditions and the patient's nutrition and
exercise requirements are addressed.317
Chronic disease management can improve
patient functioning, suppress symptoms, prevent
the development of additional diseases or co-
occurring conditions and reduce relapse.318
Relapse can result from a wide range of factors
including cravings and withdrawal symptoms;
interpersonal conflict, peer pressure and other
stressors; and the patient's emotional state,
motivation level, self-efficacy and ability to
cope with high-risk situations.319 Recent
research also points to individual differences in
brain structure as a risk factor for relapse:
patients in treatment for addiction involving
alcohol who had reduced volumes of gray
matter* in the regions of the brain associated
Gray matter volumes were measured via magnetic
resonance imaging (MRI). Gray matter is considered
a reliable indicator of neural count and functionality.
with impulse control and cognitive function
were more likely to relapse after a shorter period
of time than those with higher volumes of gray
matter in these brain regions.320 Yet another
obvious but rarely considered factor that may
contribute to relapse risk is that the treatment the
patient received simply was inadequate, either in
terms of the type of intervention provided or the
length or intensity of the treatment.321
Chronic disease management, as it applies to
addiction treatment and relapse prevention,
seeks to address and prevent those factors that
increase the likelihood of relapse by ensuring
that treatment delivery is effective and that
personal, psychological and environmental risk
factors for relapse are addressed and
mitigated.322 Specifically, physicians
supervising addiction treatment should assess
the need for chronic disease management and
323
ensure continuing care.
Medically Supervised Disease Management
Health care providers are optimally situated to
provide clinical disease management.324
Following acute treatment, the disease
management process is critical to help maintain
health and prevent relapse.325
Patients who have received acute treatment for
addiction may require maintenance medications
such as methadone, buprenorphine, naltrexone,
disulfiram or NRT to prevent relapse.326 Since
many patients with addiction have co-occurring
health conditions that may complicate their
treatment or exacerbate the risk of relapse,
medical professionals should carefully supervise
and coordinate treatment for all conditions.327
Medical professionals supervising patient care
also may perform toxicology screens to monitor
patients' substance use following acute
treatment and modify clinical interventions
accordingly.328
Medical professionals also should supervise the
psychosocial interventions that patients receive
following acute addiction treatment.
Psychosocial therapy often is a critical
component of relapse prevention.329
Collaborating with other health professionals, as
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needed, physicians should work to educate
patients about the precipitants of cravings and
relapse and help them to cope adaptively with
the associated psychological and environmental
risk factors.
The Physician Health Program
An addiction treatment model that provides
effective long-term disease management is the
Physician Health Program (PHP) established by
state medical societies and licensing boards to treat
physicians who have addiction.330 Today, all 50
states and the District of Columbia have a PHP.331
The PHP assists the participating physician in
finding clinical treatment services,332 provides case
management of individuals undergoing treatment
and maintains relationships with the authorized
treatment facilities that evaluate and treat referred
physicians.333 Contingency management in the
form of negative consequences for violating its
terms (e.g., losing one's license to practice
medicine, malpractice suits, disciplinary actions
from hospital boards) is a critical part of the
program.334 PHPs must have the oversight of a
medical director; some have an MD on staff who
serves as a medical consultant.335
Treatment managed by a PHP is more intense and
lasts longer than that for the general population,
with three to six months spent in structured therapy
followed by five years of contingency management,
and it includes pharmaceutical therapy,
psychosocial interventions and nutrition and
exercise counseling.336 PHPs also typically have a
mutual support program component.337 Long-term
monitoring is employed to reduce relapse: when
relapse or signs of possible relapse occur, the
reaction is therapeutic, not punitive.338 Physicians
who relapse tend to improve again after a treatment
adjustment.339
More than 80 percent of physicians who participate
in PHPs return to work and remain substance free
for a minimum of five years after receiving
treatment.340 Seventy-one percent of participating
physicians retain their medical license and are
employed after five years.341
Key elements of the PHP program that appear to
contribute to its success and that are replicable in
the general population include high intensity care
for an extended duration and the inclusion of long-
term monitoring and disease management.342
Case Management
Many of the activities involved in chronic
disease management and oversight can be
performed by professionally-trained case
managers working in a variety of settings such
as physicians' offices, hospital or out-patient
addiction treatment programs, justice facilities
or social service agencies. They should,
however, work under the supervision of a
trained physician and other medical
professionals.343
A Case Management Approach:
Recovery Management Checkups
Recovery Management Checkups (RMC)— in
which patients are contacted, evaluated and
linked to additional support services including
those that address co-occurring conditions-have
been shown to be an effective approach to
chronic disease management by helping patients
i • "S44
engage in and stay in treatment.
Research finds that adolescents and adults in
addiction treatment who receive RMCs-based
on a method that involves locating individuals
for checkup, assessing eligibility for
intervention, linking individuals to treatment
services, engaging participants in treatment and
retaining participation for at least 14 days in
residential treatment or seven days in intensive
or regular outpatient treatment— demonstrate
higher levels of treatment participation and
abstinence rates and reduced time to
readmission for treatment following relapse.345
Patients receiving such checkups were
significantly likelier than patients receiving
usual care to return to treatment (55 percent vs.
37 percent), do so sooner (384 days earlier) and
to be abstinent (480 days vs. 430 days) over a
two-year follow-up.346
Professional case managers can help to navigate
and coordinate resources within the fragmented
health care system and ensure that patients
receive the services they need to keep addiction
symptoms in check.347 The role of the case
manager is to link patients to the health and
social services appropriate to their specific
needs, ensure that patients follow through with
referrals, help patients identify and access a
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variety of additional support programs including
family and peer support and auxiliary services,
provide educational materials on relapse
prevention and promptly intervene in the case of
relapse.348 Monitoring the course of a patient's
treatment and connecting patients with services
when they are needed are common public health
approaches to addressing chronic illnesses.349
Case management is associated with an
increased chance that people with addiction will
access treatment for relapse, remain in treatment
for a longer period of time350 (which is
associated with better treatment outcomes),
utilize support services351 and demonstrate
improved social outcomes.* 352 A meta-analysis
of case management for patients in treatment for
addiction involving alcohol or drugs other than
nicotine found that case management can
improve patients' family and social
relationships, living situations and health.353
Support Services
Comprehensive care for patients with addiction
requires not only proper assessment,
stabilization, acute care and chronic disease
management, but support services as well.
These may include:
• Mutual support programs to bolster disease
management efforts and avoid the
recurrence of disease symptoms; and
• Auxiliary support services to address legal,
educational, employment, housing,
parenting and child-care issues that may
impede disease management.356
Health care providers are optimally situated to
facilitate links to these support and auxiliary
357
services.
Mutual Support Services
Mutual support programs, sometimes referred to
as self-help groups, can be a significant part of a
comprehensive approach to caring for a patient
with addiction. In fact, for many people with
addiction, these programs have been the main
help available to them and have been both
lifesaving and critical to helping them manage
their disease.358 These programs allow
individuals with addiction to seek and provide
social, emotional and informational support
within a group of their peers. Participation in
these programs can increase the chances of
achieving and maintaining abstinence as well as
In one study, veterans with addiction involving
illicit drugs who were assisted by case managers
experienced a larger increase in the number of days
they spent gainfully employed than their peers who
went unassisted which, in turn, was associated with
lower rates of substance use, incarceration and arrests
resulting in convictions.
An Example of an Effective Case
Management Program for Women
CASASARDSM is a welfare demonstration
program for mothers in Essex and Atlantic
counties in New Jersey who have addiction. The
program is designed to get women engaged in
treatment and employment services, help them
become sober and move successfully to stable
employment. CASASARDSM uses an intensive
case management approach to provide services
for these women.
CASA Columbia's research has found that
women with addiction involving alcohol or other
drugs (excluding nicotine) who receive income
assistance through CASASARDSM were more
likely to initiate treatment (66.5 percent vs. 50.3
percent) and complete their programs (43.5
percent vs. 22.7 percent) if they were provided
with case management services rather than
standard care. Looking at abstinence as one
outcome measure, over a 12-month post-referral
period, women participating in the
CAS ASARDSM program had a 64 percent higher
monthly abstinence rate than their peers in the
standard care program, and were likelier to have
remained completely abstinent by the end of the
12-month period (41 percent vs. 25 percent).354
After another 12 months, the abstinence rate
among CASASARDSM participants had
increased to 47 percent while the abstinence rate
among non-participants remained relatively
unchanged (24 percent).355
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help patients reduce their substance-related
problems.359 They are incorporated into many
formal treatment programs, can be an important
part of chronic disease management and
constitute the most frequently-accessed resource
among people with addiction involving alcohol
and other drugs and related problems.360
National data indicate that an average of five
million people ages 12 and older attend an
alcohol or other drug use mutual support group
each year. Slightly less than half (45.3 percent)
of the attendees participated in support groups
for addiction involving alcohol; 21.8 percent
participated in support groups for addiction
involving other drugs and 33.0 percent
participated in support groups for co-occurring
addiction involving alcohol and other drugs.* 361
Although there are many types of mutual
support programs, most have many
characteristics in common:362
• Group members share the same problem or
status;
• Groups are run using self-directed
leadership; that is, members, rather than an
outside governing figure, are in charge of
the program;
• Group members share their experiences and
lessons learned;
• Members share the goal of changing some
aspect of their personal behavior;
• Reciprocal helping is the norm;
• Members participate on a voluntary basis;
and
• Programs may accept donations but do not
charge for membership.363
Some organizations focus more on providing
fellowship, information or self-acceptance while
others attempt to address the origin of
Comparable data on rates of participation in
Nicotine Anonymous are not available.
participants' addiction problems. Programs
also vary in terms of the methods used to
address addiction, the extent to which there is an
emphasis on spirituality or religion, whether
members are encouraged to participate in
political advocacy, ' whether friends and family
members are included in group meetings, the
extent to which the group facilitates connection
with treatment professionals working in an
advisory role* and whether the program accepts
external funds.365
The 12-step groups, such as Alcoholics
Anonymous (AA) and Narcotics Anonymous
(NA) are some of the best known and most
widely available mutual support programs.5 366
They provide participants with 12 steps to
follow during the process of recovery.367 These
programs generally begin with the acceptance of
one's addiction and- thro ugh a process of self-
exploration— participants take action to make
changes toward recovery.368
Other core components of these programs are
taking responsibility for the recovery process,
sharing personal experiences, recognizing the
existence of a higher power, helping others and
lifetime commitment to the program.369 Outside
of the group meetings, sponsorship" plays an
important role in most 12-step programs. Each
new group member finds a sponsor to serve as a
role model, program guide and first line of
support in the case of a potential or actual
relapse.370 It is estimated that AA, the oldest
' e.g., unlike organizations such as Alcoholics
Anonymous (AA) and Narcotics Anonymous (NA)
which require anonymity, the Faces and Voices of
Recovery organization seeks to organize and
mobilize individuals with histories of addiction, their
families and friends in public policy advocacy
efforts.
* Professionals may work in an advisory role or they
may serve as guest lecturers.
§ There also are 12-step programs for individuals
dealing with gambling and other types of addiction,
and with a family member's or friend's addiction,
such as Al-Anon and Alateen.
** Sponsors typically have completed at least one year
of abstinence with the program and are of the same
sex as the new member (or a different sex for gay
members).
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and best known of the 12-step programs, has
more than 2,000,000 members in more than
1 14,000 groups in more than 180 different
371
countries.
Other examples of mutual support programs that
do not follow the traditional 12-steps approach
and that are secular in nature include SMART
Recovery (Self-Management and Recovery
Training),372 Secular Organizations for Sobriety
(SOS), Women for Sobriety and LifeRing
Secular Recovery.373 Groups vary based on the
population they serve.374
Participation in mutual support programs-
including 12-step and secular-based programs-
has been associated with improved
psychological functioning, reduced substance
use and reduced health-care costs and
utilization.375 However, there are
methodological limitations to the effectiveness
studies that examine mutual support programs,
restricting the extent to which their ability to
curb substance use and help manage addiction
can be determined.376 Most are not randomized
controlled studies, research on the programs is
difficult to conduct due to the anonymous nature
of group membership377 and there may be an
inherent bias in the research in that AA and
other 12-step groups may attract patients who
are more motivated to change.378 Despite the
limited empirical evidence demonstrating the
effectiveness of mutual support programs like
AA, anecdotal evidence of their effectiveness
abounds.379
One finding that emerges consistently from the
available research is that patients who had been
in addiction treatment and then followed up with
involvement in mutual support programs fare
better than those who do not.380 A study that
followed treatment patients with addiction
involving alcohol for three years found that
those who were more involved with mutual
support programs were likelier than other
patients to be abstinent the next year. Mutual
support program members who were not
abstinent the year following group participation
Including, but not limited to, AA, SMART
Recovery and Women for Sobriety.
still drank less on the days that they did consume
alcohol.381 Other research finds that those who
attend AA or another 12-step group following
treatment have about twice the rate of abstinence
as those who do not participate in these mutual
support programs.
Reviews of the research on the effectiveness of
mutual support programs suggest that it may not
be the specific content of the programs or their
processes that are associated with positive
outcomes, but rather the fact that they provide
free, long-term and easily-accessible exposure to
people and messages that support recovery,383
which is a key element of chronic disease
management.384
Twelve Step Facilitation. Twelve Step
Facilitation (TSF) is a formalization and
professionalization of the 12-step mutual support
model which involves a brief, structured and
manual-driven approach implemented over the
course of 12 to 15 sessions by a trained
counselor or treatment provider.385 During these
sessions, providers will advocate abstinence,
explain the basic concepts of the 12-steps and
actively support and facilitate the patient's
involvement in 12-step programs. TSF can be
implemented in an individual or group format or
including the patient's significant other. It has
been used in acute treatment and as a method of
providing support services for chronic disease
management.386
TSF has been used to address addiction
involving alcohol,387 marijuana and
stimulants.388 Evaluations of TSF are limited;
however, several studies have found it to be
comparable in effectiveness to psychosocial
treatments such as CBT and MET.389 It is listed
in SAMHSA's National Registry of Evidence-
based Programs and Practices390 and as an
evidence-based approach by the National
Institute on Drug Abuse (NIDA).391
Residential Programs. Some mutual support
approaches, such as the Therapeutic Community
(TC) model, are residential and incorporate
elements of treatment. Other residential
programs such as recovery homes or sober living
houses provide mutual support only. These
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programs are non-professional, generally low-
cost communal homes that provide supportive,
substance-free living environments to
individuals attempting to establish or maintain
sobriety.392 Homes may be democratically run
or hierarchically structured with house managers
in charge of other residents. Typically,
participation in additional aftercare services is
encouraged or required.393
Therapeutic Communities. The TC model, used
primarily but not exclusively with the justice
population, is a highly structured residential
program that requires a long-term commitment
(six to 24 months).394 It is based on mutual
support principles and incorporates behavior
modification techniques, education classes and
residential job duties.395 This approach aims to
re-socialize the patient to a substance-free,
crime-free lifestyle through peer influence,
personal responsibility and skill training.396 TC
participants commonly include individuals with
relatively long histories of addiction,
involvement in serious criminal activities and
significantly impaired social functioning.397 The
mutual support aspect of TCs operates on a
hierarchical basis; patients who have been
involved in the program longer provide support
and serve as role models for newer patients.398
A large, national study found that patients
enrolled for at least 90 days in a TC1 were
significantly less likely to have used cocaine (28
percent vs. 55 percent), tested positive for drug
use (19 percent vs. 53 percent), reported daily
alcohol use (9 percent vs. 15 percent) or have
spent time in jail (24 percent vs. 54 percent) a
year after program participation than those who
spent fewer than 90 days in the program.399 The
year following successful TC completion
showed lasting effects along several indicators
compared to the year prior to TC entry: the rate
of weekly cocaine use fell from 66.4 percent to
22.1 percent; weekly heroin use, from 17.2
percent to 5.8 percent; heavy alcohol use, from
40.2 percent to 18.8 percent; illegal activity,
from 40.5 percent to 15.9 percent; less than full-
Not defined.
* Long-term residential programs, most of which
were TCs.
time employment, from 87.6 percent to 77.0
percent; and reported suicidal thoughts, from
23.6 percent to 13.2 percent.400
For patients with co-occurring mental health
disorders, a Modified Therapeutic Communities
(MTC) model takes into account patients'
psychiatric symptoms,1 potential cognitive
impairments and reduced levels of functioning
due to substance use, including poor control
over urges and short attention spans. MTCs are
more flexible, less intense and more
individualized than standard TCs.401
Sober Living Houses. Sober Living Houses
provide a substance-free living environment for
individuals with addiction involving alcohol,
illicit drugs and controlled prescription drugs.
No formal treatment services are provided but
residents are mandated or strongly encouraged
to participate in mutual support programs and
must comply with house rules which include
maintaining abstinence, paying rent,
participating in house chores and attending
house meetings.402 Failure to comply with these
rules results in dismissal from the home.403
One study of the combination of participating in
a sober living house and receiving outpatient
treatment interviewed participants within their
first week of entering the houses and again at
six-, 12-, and 18-month follow-ups. § The study
found significant improvements over time on
measures of alcohol and other drug use, arrests
and employment.404
The Oxford House Model. Oxford House,
founded in 1975, is one of the most prevalent
and well-studied examples of communal-living
environments of this nature.405 Unlike sober
living houses, they encourage but never mandate
participation in mutual support programs.406
Typically, eight to 1 5 residents of the same sex
live in each home. Most recently have received
detoxification or some form of treatment and
many have been homeless or spent time in jail at
1 Although care is not medically-supervised.
§ The average length of stay in the sober living
houses was over five months but there was
considerable variation.
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some point in their lives. Homes are run
independently by the residents; there are no on-
site professional treatment providers. The
homes are supported financially by residents
who are required to pay the rent on time and
maintain their sobriety. Contrary to a chronic
disease management approach, members who
relapse are expelled immediately from the house
and must demonstrate 30 days of sobriety before
reapplying for residence.408 Residents are
expected to attend weekly meetings where house
issues are discussed and where they are
encouraged to attend mutual support
409
programs.
One study found that two years after completing
treatment and entering an Oxford House, current
and former residents were more successful at
decreasing their use of alcohol and other drugs
than those who completed treatment but simply
received standard aftercare referrals to outpatient
programs or self-help groups.410 Over that
period, those who lived in an Oxford house were
less than half as likely as those who received
usual care to use any substance (31.3 percent vs.
64.8 percent), less likely to be currently facing
criminal charges (0.0 percent vs. 5.6 percent)
and more likely to be employed (76.1 percent vs.
48.6 percent) two years later. Only 15.6 percent
of participants who had lived in an Oxford
House for at least six months relapsed after two
years and residents ages 36 and younger
demonstrated a two-year relapse rate of only 6.7
411 ~ '
percent.
Auxiliary Support Services
Patients who complete treatment successfully
may find themselves facing relapse due to the
anxiety of coping with other health problems,
unemployment, child care, homelessness,
criminal justice and other social problems.412
Matching patients with the services necessary to
address these problems decreases the risk of
relapse.413
New houses often are started with federal or state
loans stemming from the 1988 Anti-Drug Abuse Act;
the loans are paid back by the residents.
According to data from a national multi-site
study of a variety of treatment modalities, the
majority of treatment patients' perceived a need
for auxiliary support services including family
counseling services (70.9 percent),
supplementary medical care (63.5 percent),
mental health care (63.4 percent), housing (63.0
percent) and vocational services (61.4
percent).414 (Figure 5.A)
Figure 5.A
Addiction Treatment Patients' Perceived
Needs for Auxiliary Services
70.9
63.5
63.4
63.0
61.4
Family Supplementary Mental Health Housing Vocational
Counseling Medical Care Care Services
Source: CASA Columbia analysis of Friedmann et al (2004).
The perceived needs for supplementary medical,
including mental health, care underscore the
historic disconnect of addiction treatment from
medical care. Individuals who had their
perceived needs for vocational and housing
services met showed significant reductions in
illicit drug use.' 415
Evidence from a smaller study also
demonstrated that matching treatment patients
with services they need can decrease the severity
of their substance use.* Six-months after
enrolling in the study, patients who reported a
need for housing services and had their needs
matched experienced a greater reduction in their
substance use severity score compared to
patients with housing needs who were not
matched to services (50 percent vs. 23 percent
' Patients' needs were determined by their rating of a
service as "somewhat or very important." Because
patients were not randomly assigned to receive
services, the reductions in illicit drug use cannot be
linked directly to having their perceived service
needs met.
* As measured by the Addiction Severity Index.
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reduction). Similarly, patients who reported a
need for child care services and had their needs
addressed experienced a greater reduction in
their substance use severity score compared to
patients with child care needs who were not
matched to needed services (45 percent vs. 20
percent).' 416
The Use of Technology in Addiction
Treatment and Disease
Management
An emerging approach to identifying, treating
and managing addiction-the utilization of online
computer tools and other technology-based
interventions to enhance access and delivery— is
showing some promising results.417 These
include telephone contact with treatment
providers and e-mail, text messaging,
smartphone apps and online support groups.418
Online approaches that employ evidence-based
practices via Web sites or tele- or video-
conferencing offer key advantages. They can
provide psychosocial therapies to patients at
lower cost than traditional face-to-face
approaches.419 They allow patients who live far
from specialty treatment providers or who lack
resources to access psychosocial therapies or
supplemental services in a convenient manner.420
Researchers are just beginning to investigate the
utility of technology-based services for patients
with addiction. While most existing studies are
methodologically weak or flawed,421 a
randomized controlled trial of a digitally-
delivered smoking cessation intervention found
significantly higher long-term abstinence rates
compared to a control group receiving only a
self-help booklet (22.3 percent vs. 13.1
percent).422 Another randomized control study
found that patients enrolled in a methadone
maintenance program who participated in
Internet-based group therapy sessions reported
There was a 41 percent reduction among patients
who never reported needing the services. Patients
were not randomly assigned to receive services.
' There was a 3 1 percent reduction among those who
never reported needing the service.
greater satisfaction with the program than
patients who participated in traditional, face-to-
face group therapy sessions; reductions in
positive drug urine tests during the six-week
study were comparable between the two groups,
suggesting that Internet-based therapy may be an
effective treatment tool.423 A recent study found
that a smartphone-based support system shows
potential for preventing relapse in addiction
involving alcohol;424 however, further research
is needed on this particular program and, more
generally, on the outcomes of technology-based
services and how they compare to traditional
service delivery methods.425
Concerns about technology-based services
include the risks to privacy and confidentiality
of information transmitted over the Internet,
safety and efficacy, and issues of licensing
posed by treatment delivered across state
lines.426
Public Attitudes about Addictive
Substances and the Need for
Addiction Treatment
Although the American public appears to be
supportive of assuring that individuals with
addiction receive effective addiction treatment,
the view of most individuals about the relative
need for treatment for individuals who use
addictive substances and what constitutes
effective treatment does not match the science of
best practices.
Perceptions of the Relative Need for
Treatment Based on Substance of
Addiction
CAS A Columbia's NAB AS found significant
differences in respondents' views of the type and
extent of substance use that indicates a substance
use problem and the need to seek treatment.
Public perceptions do not reflect the continuum
of substance use or distinguish between risky
use and the need for intervention versus
addiction and the need for treatment:
• The majority of respondents reported that
any use of the illegal drugs heroin (84.0
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percent), cocaine (76.0 percent) or
methamphetamine (73.9 percent) indicates
that the user has a serious problem and
should seek treatment.
42.5 percent thought that any misuse of a
controlled prescription drug is a serious
problem requiring treatment; 29.6 percent
thought that daily or more than daily misuse
of these drugs is serious enough to require
treatment.
35.8 percent felt that any use of marijuana
indicates that the user has a serious problem
and should seek treatment; the same amount
(35.9 percent) thought that daily or more
than daily use of marijuana is a serious
problem that requires treatment.
complete abstinence should be the main goal of
treatment for individuals with addiction
involving illicit drugs (65.7 percent), alcohol
(60.0 percent), tobacco (50.1 percent) or
controlled prescription drugs (47.1 percent).
Whereas the next most common response for the
goal of addiction treatment was that the goal
should be set by the patient, a small but
significant proportion indicated that reduced use
should be the primary goal; this was particularly
true for addiction involving prescription drugs,'
tobacco and alcohol, but less so for addiction
involving illicit drugs. A focus solely on
reducing the negative consequences of substance
use (the "harm reduction" approach) rather than
reducing or eliminating use was endorsed by
fewer than five percent of the respondents as a
main goal of treatment.428 (Figure 5.B)
78.0 percent reported
that alcohol use is a
serious problem
requiring treatment if
it occurs daily or
more than daily; 6.8
percent reported that
any drinking is a
serious problem
requiring
treatment.
427
49.5 percent felt that
smoking was a
serious problem
requiring treatment if
it occurred on a daily or more than daily
basis; 24.3 percent reported that any
smoking is a serious problem requiring
treatment.
Figure 5.B
Public Perceptions of the Goals of Treatment
60.0
50.1
n
47.1
29.7
21.1
"114.6
7.6
22.7
20.!
3.5
Illicit Drugs
Alcohol
Tobacco
Prescription Drugs
i Complete
Abstinence
i Goal Set by
Patient
i Reduced Use
1 Fewer Negative
Consequences
Source: CASA Columbia National Addiction Belief and Attitude Survey (NABAS), 2008.
Perceptions of the Goals of Treatment
From a medical perspective, the goal of
addiction treatment would be to restore and
maintain health and eliminate or reduce risky
behavior that threatens health and safety. Most
respondents to the NABAS indicated that
In the NABAS survey, respondents were asked
which of the following they thought should be the
main treatment goal for someone with addiction
involving tobacco, alcohol, illicit drugs and
prescription drugs: complete abstinence, reduced
use, fewer negative consequences from use, or that
the goal should be set by the patient.
' For prescription drugs, reduced use was a more
common response (22.7 percent) than that the goal
should be set by the patient (20.8 percent).
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Perceptions of the Types of
Interventions that Constitute Treatment
Although a wide range of psychosocial and
pharmaceutical therapies are available to
treat addiction, 60.1 percent of respondents to
the NABAS spontaneously offered mutual
support programs such as AA or NA as a
"treatment" intervention when asked what
kinds of treatment come to mind when they
think about treatment for addiction. This is
despite the fact that a mutual support
program, while a very helpful resource to
many individuals with addiction, is not an
evidence-based treatment for the disease.
Forty percent (39.9 percent) mentioned a
hospital visit, 1 1.7 percent mentioned residential
rehabilitation clinics and 10.4 percent mentioned
outpatient treatment as what comes to mind
when they think of addiction treatment (although
these are treatment venues, not treatments
approaches). Although only 1 1.6 percent
mentioned the utilization of prescription
medications for treating addiction (Figure 5.C),
a separate question found that 54.7 percent of
respondents (46.8 percent of those with a history
of addiction) stated that it is good that there are
medicines to treat addiction because addiction is
a medical condition that medicine can help.
Perhaps reflective of a lack of knowledge about
effective treatment for addiction, 38.3 percent of
respondents (48.6 percent of those with a
history of addiction) indicated it is not good
news that there are medicines to treat
addiction because treating addiction with
medication only serves to replace one
addiction with another
429
Some individuals with addiction may not
access appropriate treatment because of the
belief that the use of pharmaceutical
treatments, such as methadone, to treat
addiction is contrary to the abstinence-based
perspectives of addiction treatment espoused
by many mutual support/ 12-step programs. A
recent study found that adherence to such
beliefs leads many heroin users to underutilize
methadone maintenance therapy despite their
knowledge of its effectiveness.430
Figure 5.C
Public Perceptions of the Types of Interventions
that Constitute Treatment
60.1
39.9
11.7
11.6
10.4
Mutual Support Hospital Visit Residential Prescription Outpatient
Program Rehab Clinic Medication Treatment
Source: CASA Columbia National Addiction Belief and Attitude
Survey (NABAS), 2008.
Perceptions of the Effectiveness of
Treatment
Despite respondents' limited awareness of
effective science-based treatments for addiction,
the majority of respondents to the NABAS
reported believing that if a person admits to
having a problem and wants to get better,
addiction treatment is somewhat or very
effective: approximately eight in 10 indicated
that treatment for addiction involving alcohol
(82.5 percent) or prescription drugs (79.9
percent) is effective, and about three quarters
indicated that treatment for addiction involving
illicit drugs (73.6 percent) and tobacco (73.1
percent) is effective.431 (Figure 5.D)
Figure 5.D
Percent of Public Agreeing that
Addiction Treatment Is Somewhat/Very Effective,
by Substance Involved
82.5
79.9
73.6
73.1
Alcohol
Prescription Drugs Illicit Drugs
Tobacco
Source: CASA Columbia National Addiction Belief and Attitude
Survey (NABAS), 2008.
It is important to note, however, that a significant
proportion of the public defines treatment in a way
that is not consistent with the science of best
practices in treatment.
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These data are consistent with those of other
recent surveys. One found that the majority of
Americans believe that treatment programs can
help people with addiction involving alcohol (8 1
percent), prescription drugs (79 percent),
marijuana (78 percent) or other illicit drugs (69
percent).432 Another found that 88 percent of
Americans believe that addiction treatment is
extremely or very important in helping people
get better and 77 percent believe that long-term
recovery is unlikely to be successful without
treatment and continued support.433
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Chapter VI
Tailored Treatment for Special Populations
Diseases manifest differently in different
individuals and, as with other health conditions,
a one-size-fits-all approach to addiction
treatment typically is a recipe for failure.1 For
addiction treatment to be effective, it must be
tailored to the individual patient, including the
particular stage and severity of the disease,
overall health status including any co-occurring
conditions, past treatments and any other life
circumstances that might affect patient
outcomes.2 Treatment approaches also must be
appropriate to the patient's age, gender,
race/ethnicity and cultural background.3
Although research on the effectiveness of
various treatment approaches for special
populations is very limited, particular subgroups
for whom there is some documented evidence of
the benefits of specialized treatment include:
those with co-occurring health conditions,
adolescents, women, older adults, racial and
ethnic minorities, individuals of minority sexual
orientation, veterans and those in active duty
military, and individuals involved in the justice
system.
Co-occurring Medical Disorders
Because addiction causes, contributes to and co-
occurs with multiple other diseases, including 70
other conditions requiring medical care such as
heart disease and cancer, ' 4 physicians and other
medical professionals must address these co-
occurring health conditions in the course of
caring for their patients and assure that
medication interactions and the use of
The following discussion is a brief overview of
tailored treatment approaches for special populations
and is not an exhaustive or definitive account of all
possible treatments of this nature. More research is
needed to identity the best treatment approaches for
the special populations discussed in this chapter as
well as for others not included here.
f See Chapter III.
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potentially addictive medications are considered
and monitored.5
For example, patients treated with opioids for
pain may be at risk for developing addiction,
particularly if they do not take them as
prescribed.6 Likewise, the frequent use of
addictive substances such as cocaine can result
in a range of gastrointestinal and cardiac
complications that can affect various organs in
the body; medications used in detoxification and
addiction treatment may further complicate these
medical conditions.7
The efficacy of particular addiction treatment
approaches has not been examined
systematically in patient populations with co-
occurring medical conditions. However,
medical and other health professionals should
plan carefully the treatment protocols for
patients with co-occurring addiction and other
medical conditions, be prepared to monitor and
address emergent reactions that may arise in the
course of treating these patients and consult with
specialists in other medical sub-specialties when
necessary.8
Co-occurring Mental Health
Disorders*
In the late 1 970s, treatment professionals began
to recognize the effect that co-occurring mental
health disorders had on patients' success in
addiction treatment. Around the same time,
treatment professionals and programs began to
document the large number of addiction and
mental health treatment seekers suffering from
both sets of problems/ 9
Traditionally, patients with co-occurring
addiction and mental health disorders were sent
to one treatment setting or another to address
their problems sequentially.10 Patients have
The treatment programs discussed in this section
represent the main evidence-based treatment
modalities for individuals with co-occurring
addiction and mental health disorders. It is not a
comprehensive list of available programs.
* See Chapter III for data on the prevalence of co-
occurring addiction and mental health disorders.
been advised either to "solve" their addiction
problems before entering mental health
treatment or stabilize their mental health
problems before entering addiction treatment.11
This approach has not been effective since each
condition tends to exacerbate the other.12
Current standards call for treatment programs
serving patients with addiction and mental
health disorders to provide integrated care that
treats both conditions simultaneously.13
Treatment providers may coordinate addiction
and mental health treatment services by
combining therapies or by managing the care
while patients receive both types of treatments
concurrently. 14
Integrating addiction treatment and mental
health care for patients with co-occurring
disorders increases retention and yields positive
outcomes, including higher abstinence rates and
reduced hospitalization and arrest rates.16
Integrated treatment also helps providers prevent
adverse drug interactions among their patients
and ensure that proper medication dosage is used
to treat both conditions.17
Essential Program Components and
Principles for Treating Patients with
Co-occurring Disorders15
• Coordinated treatment and recovery plan;
• Access to addiction and regular medical and
mental health services within the same
facility or through collaborating programs;
• Specialists to provide addiction treatment,
psychiatric services and other health care
services as needed;
• Patient information about the nature of the
disorders, the importance of lifestyle
changes and adherence to treatment
regimens and strategies for relapse
prevention;
• Comprehensive support services to address
issues such as housing and unemployment;
• Access to mutual support programming; and
• Reintegration of patients with their families
and communities.
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Tobacco Cessation
Smoking rates are high among individuals with
mental health disorders, due to common
neurobiological and psychosocial risk factors,
the tendency to smoke as a means of self-
medication and a reduced ability to manage the
difficult process of cessation.18
Practice guidelines for smoking cessation
underscore the importance of providing smoking
cessation services to patients with co-occurring
mental health disorders, utilizing motivational
and cognitive-behavioral approaches and
combining psychosocial therapies with
pharmaceutical interventions-practices that
mirror those that are recommended for the
general population.19 However, in implementing
these approaches, care must be taken to ensure
that interventions are tailored to the clinical
needs of the patient and that such interventions
do not contraindicate other treatments the patient
might be receiving for his or her mental illness.20
Bupropion has been approved by the FDA as
both a smoking cessation medication and an
antidepressant, making it uniquely suited to treat
individuals with co-occurring mood disorders
and addiction involving nicotine.21 Preliminary
findings indicate that use of bupropion, in
conjunction with nicotine replacement therapy
(NRT), can be particularly helpful in treating
patients with co-occurring mental health
disorders.22 However, research on smoking
cessation interventions in populations with co-
occurring mental health disorders is very
limited, in part because patients with such
disorders historically have been excluded from
many smoking cessation studies.23
Monitoring a patient's smoking and cessation
activities is extremely important for those with
mental illnesses since tobacco use can affect the
treatment of mental health disorders.24 For
example, because smoking may influence the
metabolism of certain commonly prescribed
psychiatric medications, dosages of these
medications may need to be adjusted when a
Smokers typically need twice the dosage of these
medications than nonsmokers.
patient is cutting back or quitting their ingestion
of tobacco products.25
Treatment for Addiction Involving Alcohol
and Other Drugs
Psychosocial interventions have proven effective
for patients with co-occurring mental health
disorders and addiction.26 Patients with co-
occurring schizophrenia and addiction appear to
respond positively to psychosocial approaches
that include cognitive behavioral therapy (CBT),
motivational interviewing (MI) and family
therapy components.27 Patients with co-
occurring addiction and mood disorders respond
well to behavioral skills training.* 28 Integrated
group therapy (IGT), a CBT-based intervention
for co-occurring addiction and bipolar disorders,
was found to be significantly more beneficial
than a standard group therapy program: in one
study, IGT patients used alcohol and other drugs
half as often as other patients did during the
intervention and three months after treatment.29
There also is evidence of the efficacy of
pharmaceutical interventions for patients with
co-occurring disorders.30 Antidepressants,
including selective serotonin reuptake inhibitors
(SSRIs), are an effective pharmaceutical
treatment for many individuals with co-
occurring mood disorders and addiction
involving alcohol31 and may be effective for
patients with co-occurring mental health
disorders and addiction involving opioids or
sedatives as well. Stimulating antidepressants,
such as desipramine or bupropion, may be more
useful for treating patients with co-occurring
depression and addiction involving cocaine.32
Preliminary research also suggests that certain
anticonvulsant medications may be effective in
treating patients with co-occurring mood or
anxiety disorders and addiction involving
alcohol.33
1 The behavioral skills training model utilized a
psycho-educational approach to teach patients self-
management skills and provide opportunities for
practice.
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While evidence regarding effective treatments
for addiction and co-occurring trauma disorders
is limited, psychotherapeutic approaches,
typically involving CBT and a
psychoeducational component, appear to be
quite effective.34
Adolescents
Treatment approaches for adolescents must be
tailored to the profound neurochemical,
physical, cognitive, emotional and social
changes that take place during adolescent
development and to the heightened influence of
family and peers relative to adult patients.41
Because early initiation of substance use is
related so strongly to the risk of addiction,42
interventions for young people demonstrating
early signs of risky substance use and treatment
for addiction is imperative.43 Treatment
approaches with a strong evidence base in adult
populations are not necessarily applicable to the
treatment needs of adolescents with addiction.44
The clinical presentation of addiction often
differs in adolescents compared to adults:
adolescents typically do not demonstrate the
same extent of physical dependence (i.e.,
tolerance and withdrawal) symptoms;
progression from use to addiction often is more
rapid; and co-occurrence with mental health
disorders is more common.45
Treatment programs for adolescents should be
developmentally appropriate and family
oriented.46 Special care should be taken when
providing group-based therapy to adolescents
who may be more vulnerable than adults to
potential negative peer influences; this is
especially true when the group contains
members with significant behavioral problems.47
A significant proportion of adolescents with
addiction have histories of trauma or adverse life
experiences as well as co-occurring disorders
that must be addressed in treatment.48
Tobacco Cessation
A range of effective options exists for teen
smoking cessation, including NRT,49 educational
programs that offer life-skills training and
counseling interventions.50 A meta-analysis of
48 smoking cessation program studies from
1970 to 2003 for adolescents ages 12-19 found
that the odds of quitting for smokers in these
programs increased by 46 percent. Higher quit
rates were found in programs that included
Integrated Treatment for
Co-occurring Disorders
Originally developed to treat patients with a
serious mental illness, Assertive Community
Treatment (ACT) was modified in the late 1990s
to serve patients with co-occurring addiction and
mental health disorders.35 The ACT model is an
effective way of delivering integrated dual
disorders treatment (IDDT), also known as
integrated treatment for co-occurring disorders.
This integrated approach to treatment for people
with mental illness and addiction should include
the following components: staged interventions,
assertive outreach, motivational interventions,
counseling, social support interventions, a long-
term perspective to treatment, comprehensiveness
and cultural sensitivity and competence.36 The
approach relies on a multidisciplinary team of
providers and intensive outreach activities-
including providing services to patients in their
homes and communities— to keep participants
actively engaged in a high-intensity outpatient
treatment model.37 The services provided
combine treatment approaches such as
motivational interviewing (MI) or cognitive
behavior therapy (CBT) with support services
such as psycho-educational instruction about
addiction, 12-step mutual support programming
and life skills training.38 Patients are monitored
closely and have access to crisis intervention
services 24 hours a day.39
Participation in this type of program is associated
with reduced alcohol and other drug use (based on
clinicians' reports), reduced hospital utilization,
lower post-treatment relapse rates and improved
quality of life.40
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motivational-enhancement therapy (MET), CBT
and social influence approaches in which
adolescents address the influences that promote
or maintain smoking behavior.51
Treatment for Addiction Involving Alcohol
and Other Drugs
Psychosocial therapies such as CBT52 and
family-based therapies are effective treatments
for adolescents with addiction.53 Interventions
that integrate a family component into
psychosocial interventions are particularly
effective for adolescent patients.54 Adolescents
generally seem to fare better in treatment
programs that include family members in
counseling sessions or that encourage families to
take an active role in the treatment process.55
Particular types of family-based therapies that
have proven effective for adolescents include:
• Multidimensional Family Therapy (MDFT)--
an outpatient family-based treatment program
that addresses adolescent alcohol and other
drug use in relation to individual-, family-,
peer- and community-level influences.56 One
study found that adolescents who received
MDFT were likelier than those who received
other interventions, such as group therapy or
educational interventions, to complete their
treatment and to demonstrate reduced alcohol
and other drug use directly following
treatment and one year later.57
• Functional Family Therapy (FFT)--a
comprehensive approach to treatment
implemented in the home or in clinical or
school settings based on the idea that
behaviors influence and are influenced by
multiple systems in the adolescent's life,
including the family. The three-month
program consists of engaging and
motivating adolescents and families; the
development and implementation of an
individually tailored, long-term behavior
change plan; and an attempt to generalize
positive behavior change to other areas of
family functioning. Research suggests that
interventions that include FFT produce
better treatment outcomes than those
without an FFT component.58
You have an addicted family system. The family
needs education and therapy, especially with
adolescents in treatment.59
-John Coppola
Executive Director
New York Association of Alcoholism and
Substance Abuse Providers, Inc. (ASAP)
...It is clear the family plays an important role in
encouraging and supporting recovery, especially
in adolescents.60
-Jose Szapocznik, PhD
Professor and Chair,
Department of Epidemiology and Public Health
Director, Center for Family Studies
Director,
Miami Clinical
Translational Science Institute
• Multi-Systemic Therapy (MST)-a family-
based approach to addressing risk factors
associated with serious antisocial behavior
in children and adolescents who use alcohol
or other drugs. The treatment generally
takes place in familiar environments (homes,
schools or other neighborhood settings)
which contributes to a high retention rate.61
In addition to addressing substance use,
MST also attempts to reduce criminal and
other forms of problem behavior and
decrease future involvement with juvenile
justice and child welfare systems.62 MST is
associated with reduced alcohol and other
drug use during treatment and for at least six
months following program completion,63
and is particularly effective for those
involved with the juvenile justice system.64
A large study of adolescent treatment
participants in different types of programs
found that in the year following treatment, the
percentage of adolescents using marijuana at
least weekly was cut by approximately half.
The study included more than 1,100 adolescent
treatment participants from 23 different programs in
four cities.
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Heavy drinking rates fell from 33.8 percent to
20.3 percent. The rate of criminal activity also
declined and indicators of psychosocial
adjustment, school attendance and academic
performance improved significantly.65
As is true for adults, comprehensive and
continuing care is critical for adolescents with
addiction. Assertive continuing care (ACC) is a
method of enhancing engagement in treatment
by moving responsibility for service utilization
from adolescents and their caregivers to
treatment providers.66 ACC is characterized by
at least weekly face-to-face sessions conducted
in the home or community settings that are
convenient for the adolescent and increase the
likelihood of retention and low patient-to-
provider ratios. Interventions used in ACC
include an adolescent-oriented community
reinforcement approach (A-CRA) and intensive
case management.67 Research on this approach
demonstrates that adolescents receiving ACC
were significantly likelier to be abstinent from
marijuana following discharge from residential
treatment than adolescents who did not receive
ACC;* they also had higher rates of retention in
aftercare services.68
Very few studies have examined the use and
effectiveness of pharmaceutical interventions for
the treatment of adolescent patients with
addiction involving alcohol or other drugs;69 best
practice suggests that if they are employed they
should be used as a supplement to psychosocial
therapies.70
Women
A considerable body of evidence demonstrates
the importance of addressing gender differences
in the treatment process, particularly for women
with histories of trauma and those who are
pregnant or parenting.71 Women often smoke,
drink and use other drugs for different reasons
than men and addictive substances affect women
All participants received referrals to adolescent
outpatient treatment providers for continuing care in
their communities following discharge from
residential treatment.
differently than men; this may indicate different
treatment needs.72 Because the life roles and
responsibilities of women typically differ from
men, their support service needs may differ as
well.73 Women with addiction have high rates
of co-occurring mental health disorders,
including mood, anxiety and eating disorders
that should be addressed in the treatment
process, and high rates of trauma histories that
can influence treatment outcomes.74
Gender-specific treatment programs appear to be
particularly beneficial for women with a history
of sexual abuse and domestic violence.76
Women who were abused as children suffer
from substance-related problems that are more
severe than those of their peers, including
lifetime use of a greater number of substances,
higher alcohol and other drug severity scores'
and greater financial and interpersonal
problems.77 Women who report exposure to
physical, sexual or emotional abuse during
childhood are more prone to relapse than other
treatment patients, and may be less likely to
improve during and after treatment.78 Women
with trauma histories require a more
empowering and less confrontational approach;
being told that they are powerless over their
addiction-a common tactic in many treatment
programs that are centered on the 12-step model-
-can bring back feelings of powerlessness from
sexual and other abuse.79
Pregnant Women
Pregnant women require special consideration in
stabilization, acute treatment and disease
management protocols, particularly with regard
1 Based on the Modified Michigan Alcohol-Drug
Screening Test.
The safety and security of 'all female '
[programs] allow women to disclose things that
are very difficult and that may be impossible
within a co-ed arrangement. It enhances a
woman's ability to feel understood and accepted
75
without judgment, shame or guilt.
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to pharmaceutical interventions. Withdrawal
from addictive substances during detoxification
can be highly risky to a fetus; for example,
sudden withdrawal from certain opioids and
sedatives can lead to fetal distress or death.81 As
a result, detoxification protocols should include
careful monitoring of the pregnant woman and
her fetus and medical supervision of the
detoxification process itself— for example,
through the use of buprenorphine to treat or
prevent opioid withdrawal during pregnancy '—
preferably under the direction of a physician
with experience in perinatal addiction.82
Medically supervised detoxification typically
takes place during the second trimester because
of the risk of miscarriage in the first trimester
and the increased risk of premature delivery or
fetal death in the third trimester.83
Research on the safety and efficacy of
pharmaceutical therapies for addiction treatment
among pregnant women is limited.84 Certain
medications, such as disulfiram, are not
considered safe for pregnant women, while
others, such as methadone, are less risky and
may be preferable to continued substance use.85
Case management is particularly critical for
pregnant women with addiction.86 Case
management services typically assure
standardized assessments, access to prenatal and
pediatric care, mental health services, vocational
and parenting classes, childcare and
87
transportation services.
Pregnant women with co-occurring addiction
and mental health disorders require additional
medical monitoring because pregnancy can
aggravate certain symptoms of mental illness,
including depression and anxiety.88 Hormonal
changes, increased stress and pregnancy-specific
medications all can contribute to the potential
exacerbation of mental illness symptoms.89
Specific psychosocial treatment approaches that
work for pregnant women with addiction do not
appear to differ from those found to be effective in
the general population of women.
' Opioid withdrawal during pregnancy can lead to
fetal death.
Although federal law requires that pregnant
women receive priority admission into addiction
treatment programs, allowing them to bypass
waiting lists,90 numerous barriers prevent many
pregnant women from accessing needed
treatment.1 While pregnant women may be
more motivated than other women to receive
addiction treatment because of the known risks
of substance use to pregnant women and their
babies, they are less likely to stay in treatment
once admitted, and reductions in substance use
often are transient and dissipate once their
children are born.91
Older Adults
Treatment approaches for older adults must take
into account their increased risk of developing
addiction involving prescription drugs due to the
use of medication to treat chronic pain, sleep
disorders, depression and anxiety-problems that
are common in this age group— as well as the
fact that their bodies become even more
vulnerable to the effects of alcohol and other
drugs with age.§ 94 Co-occurring health
conditions and medical complications due to
age-related health problems can interfere with
addiction treatment and make it harder for older
adults to follow treatment instructions and
plans.95
1 See Chapter VII.
§ See Chapter IV for a discussion of the unique risks
that older adults face with regard to substance use
and addiction.
The Center for Substance Abuse Treatment's
(CSAT) Pregnant and Postpartum Women
demonstration program provided comprehensive
clinical, medical and social services, over the
course of six to 12 months, to pregnant women
and mothers of children under the age of one.92
During the six months following discharge from
this program, 61 percent of the women had
achieved and maintained their abstinence from
alcohol and other drugs. Program participation
also was associated with increased employment
rates and decreased rates of arrest, foster care
involvement and premature deliveries, low birth
weight and infant death. 93
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Psychosocial interventions, particularly
motivational interviewing (MI) and motivational
enhancement therapy (MET), are regarded as
effective approaches for older adults, especially
those who may resist changing their substance
use behavior.96
Before prescribing a potentially addictive
medication to an adult patient, a full assessment
of the patient's use of other addictive substances
and deliberate counseling with regard to the
risks of physical dependence and the dangers of
combining addictive substances is necessary.
When treating older patients with
pharmaceutical therapy, long-acting
benzodiazepines and disulfiram should be
avoided because of their toxicity. Naltrexone
has been tolerated well by older adults and there
is some evidence of its effectiveness in this
population.97
To improve treatment compliance, older patients
also may require specialized services to assure
appropriate interventions for dietary deficiencies
or auditory or visual impairments; to provide
psychosocial interventions that help patients
cope with loneliness, loss or depression which
are more common in this age group; and to help
bolster supportive social networks.98
Racial and Ethnic Minorities
Treatment providers should take into
consideration the substance-related health
disparities-including the likelihood of co-
occurring disorders— that exist among
racial/ethnic groups.* 99 Different racial/ethnic
groups also may vary in their metabolism,
response to dosages and side effects of
pharmaceutical interventions for addiction.100
While data are not available on specific
psychosocial therapies that work best for
e.g., Whites and Hispanics have a higher severity of
alcohol problems than other racial/ethnic groups (see
Chapter III); Hispanic and black men have higher
rates of cirrhosis mortality than white men; and
Alaska Native and white men report higher rates of
alcohol-related and non-alcohol-related major
depressive disorder than Hispanic and black men.
particular racial/ethnic groups, treatment
providers should ensure that programs are
effective for individuals of every racial and
ethnic background by making them sensitive to
racial, ethnic and cultural conditions that may
affect the treatment process.101 For example,
providers should make sure that language
barriers are addressed and require cultural
competency training for staff.102 These
measures improve communication and increase
trust and understanding, which in turn result in
greater recognition of patients' needs, increased
patient engagement in treatment and better
treatment compliance.103
Individuals of Minority Sexual
Orientation
Treatment goals for lesbian, gay, bisexual and
transgender (LGBT) individuals are the same as
treatment goals for other individuals in terms of
reducing use or achieving abstinence, but
treatment should also focus on the unique
characteristics of LGBT patients. For example,
higher rates of discrimination against lesbian,
gay and bisexual adults may be associated with
higher rates of risky use and addiction in this
population, compared with heterosexuals.104
Treatment providers should screen for other
health problems and adverse experiences that
may be more common in the LGBT population
including co-occurring mental health disorders,
suicidal thoughts or behaviors, sexually-
transmitted infections (in particular HIV/AIDS
and hepatitis A and B) and sexual abuse.105 Gay
and bisexual men make up nearly half of those
living with HIV in the United States;106 the
prevalence of mental health disorders is higher
among lesbian, gay and bisexual adults' than
among heterosexual adults;1 107 and a review
study found that lifetime prevalence estimates of
sexual abuse range from 15.6 percent to 85.0
percent for lesbian or bisexual women and from
11.8 percent to 54.0 percent for gay or bisexual
Or those who report same-sex sexual partners.
Or those who report opposite-sex sexual partners.
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When assessing available social support for
LGBT patients, treatment providers should
recognize that LGBT individuals may
experience conflict with their family of origin,
especially around issues of sexual orientation or
gender identity, and it is important for treatment
providers to understand the interpersonal
relationships of their LGBT patients. In
addition, providers should be particularly careful
to protect the confidentiality of LGBT patients
because in many states LGBT individuals lack
legal protections against discrimination in
housing, the job market or social services.109
Despite the need to tailor addiction treatment to
the needs of LGBT individuals, national data
show that only 6.2 percent of treatment facilities
offered any type of tailored treatment
specifically for LGBT patients in 2010.110 A
2007 national study found that services provided
by 70.8 percent of LGBT-specialized programs
did not differ from services provided to patients
in other programs and only about seven percent
of facilities offered LGBT-specific services,
such as special groups for LGBT patients or
having counselors who were trained specifically
in LGBT issues.111
Research evaluating the impact of treatment
specific to the needs of LGBT individuals is
lacking. Among a small sample of individuals
in addiction treatment, gay and bisexual men in
LGBT-specialized treatment reported better
outcomes, such as achieving abstinence and
completing treatment, than gay and bisexual
men in traditional treatment.112
Veterans and Active Duty Military
The U.S. Department of Veterans Affairs (VA)
and the Department of Defense have developed
practice guidelines for evidence-based addiction
treatment, and endorsed the U.S. Public Health
Services' Clinical Practice Guidelines for
smoking cessation.113 Among the recommended
practices for addressing risky use of addictive
substances and addiction in veterans and active
duty members of the military are the
following:114
• Active duty members involved in an
incident in which substance use is
suspected to be a contributing factor are
required to be referred to specialty
addiction care for evaluation.
• A treatment team shall convene with the
patient and command in order to review the
treatment plan and goals.
• Rehabilitation and referral services for the
patient require an individualized plan
designed to identify the continued support
of the patient with at least monthly
monitoring during the first year after
inpatient treatment.
• For patients who do not stabilize and refuse
to engage in any type of ongoing care with
any provider (e.g., medical, psychiatric or
addiction specialty), consider involving
supportive family members or significant
others if the patient agrees. This may
include a first line supervisor when
appropriate and the unit commander.
Of particular importance in the veteran and
active duty military populations is the need to
attend to co-occurring mental health conditions,
particularly post-traumatic stress disorder
(PTSD), which are common in this
population.115
The VA has outlined certain treatment
guidelines for veterans and military personnel
with addiction and co-occurring PTSD, most of
which mirror the treatment approaches outlined
in Chapter V for the general population.
However, the VA notes that treatment for the
two conditions can be delivered simultaneously,
that the clinician should use first-stage treatment
approaches such as motivational interviewing to
initiate treatment and specifically states that
tobacco cessation services should be integrated
into the treatment protocol.116 The most
commonly used treatment approach for veteran
patients with co-occurring addiction and PTSD
involves cognitive behavioral therapy (CBT).117
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The importance of attending to co-occurring
conditions in this population is highlighted by a
study of veterans with co-occurring PTSD and
addiction who participated in addiction
treatment* 118 This study found that receiving
treatment for PTSD during the initial year of
addiction treatment almost quadrupled
participants' odds of being in remission from
addiction^ five years later.119
Individuals Involved in the Justice
System
In 2006, the National Institute on Drug Abuse
(NIDA) developed evidence-based principles for
the effective treatment of individuals in the
justice system who have addiction. These
principles include providing comprehensive
assessments of the extent and severity of
offenders' substance involvement, addressing
the presence of co-occurring conditions that
might call for specialized treatment services,
assessing treatment progress and adjusting
interventions accordingly.120
For both juveniles and adult offenders with
addiction, the use of treatment-based alternatives
to incarceration represents an important step in
treating the disease. Drug courts, prosecutorial-
based diversion programs and intensive
treatment-based probation are some of the
approaches that have proved effective in the
justice field.121 Services also can be provided by
professionals, using evidence based practices,
during incarceration and after release. These
initiatives provide addiction treatment, assure
collaboration between justice authorities and
treatment providers and hold the offender legally
accountable for treatment compliance.122
The sample was drawn from male inpatients
participating in a multisite VA program evaluation of
addiction treatment.
' Defined as having (1) abstained from all 13
substances investigated, (2) had no problems related
to alcohol or other drugs and (3) consumed 3 oz.
(88.79 ml) or less of alcohol per day on maximum
drinking days in the past month. Freedom from
problems related to substance use was reflected by a
response of "never" to each of 15 problems in the
areas of health, work, legal situation and finances.
Juvenile Offenders
Comprehensive treatment and management of
addiction in the juvenile justice population result
in decreased substance use, crime (recidivism),
homelessness and high-risk sexual behavior;
improved school performance, productivity,
employment and future earning power; and
better health and psychological adjustment.123
For adolescents in the juvenile justice system,
screening and comprehensive assessments are
critical for identifying an adolescent's needs and
for connecting the juvenile with effective
interventions and treatments. Comprehensive
assessments can take place at various points,
including at the first interview after referral to
juvenile court (often conducted by an intake
officer) where results may be used to refer the
adolescent to more appropriate community
health services rather than incarceration.
Assessments also may be conducted upon
admission to a pre-trial detention center to await
adjudication or upon admission to a post-
adjudication community program or correctional
facility.124
Addiction treatment for juvenile offenders
should reflect the standards of evidence-based
care for adolescents in the general population,
with a special focus on family-based treatment
models. Effective treatment approaches include
multidimensional family therapy (MDFT),
functional family therapy (FFT) and multi-
systemic therapy (MST).125
Adult Corrections
Treatment tailored to criminal justice
populations should ensure that treatment plans
correspond with correctional supervision
requirements as well as the medical and social
support services that the patient may need.126
Cognitive behavioral therapy (CBT),
motivational enhancement therapy (MET) and
contingency management (CM) have been
shown to be effective treatment approaches for
inmates,127 particularly in that they help train
patients to recognize errors in judgment that lead
to substance use and to criminal behavior,128 and
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help to increase treatment engagement and
retention.129 As is true in the general population,
evidence-based pharmaceutical interventions
should be provided to patients in the criminal
justice population along with psychosocial
therapies.130
Individuals with addiction facing release and
reentry should be assured appropriate post-
release community-based treatment, disease
management and support services.131
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Chapter VII
The Addiction Treatment Gap
In spite of the facts that 15.9 percent of the U.S.
population ages 12 and older report meeting
clinical criteria for addiction and that evidence-
based interventions and treatments are widely
available, research clearly indicates that only a
small fraction of those in need of addiction
treatment receives it and, of those who do, few
receive evidence-based care. Determining the
exact size and shape of the addiction treatment
gap in this country is impossible due to
significant data limitations;* however, 89.1
percent of those who meet criteria for addiction
involving alcohol and drugs other than nicotine
report receiving no treatment f at all.* 1
There are no national data on the total number of
people who receive treatment for the disease. Rather,
existing data on addiction treatment exclude
addiction involving nicotine, and data on the types of
services offered and venues in which they are
provided are available only for providers that receive
public funds. Because some addiction treatment
providers accept both public and private funding, the
available data on providers serving publicly-funded
patients also include an unidentifiable number of
patients who receive private funding.
f For the purposes of the present analyses, treatment
includes: (1) services received at non-intensive or
intensive non-residential settings (including alcohol
or other drug rehabilitation facilities, mental health
centers or facilities or doctors' or mental health
professionals' private offices); and (2) short- or long-
term residential settings (including alcohol or other
drug rehabilitation facilities, hospital or mental health
centers or facilities) in the past 12 months.
Detoxification, services received in an emergency
department or in prison or jail settings, mutual
support programs, peer counseling and other support
services (including religious-based counseling) are
excluded from these analyses.
* While 31.7 percent of the U.S. population ages 12
and older engage in risky use but do not meet criteria
for addiction, there has been no attempt to document
nationally the proportion of this population that
receives evidence-based screening and brief
interventions, leaving the size of the intervention gap
for risky users unknown. Therefore, this chapter
focuses exclusively on the treatment gap for
individuals with addiction.
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Of those whose addiction involves nicotine, the
only data available are for persons ages 1 8 and
older who have tried to quit smoking; less than
one-third (31.7 percent) of these individuals
receive smoking cessation services.1 2
A key factor contributing to the treatment gap is
the way treatment costs are covered. In contrast
to the role of private insurance in medical care
spending-where it covers 55.6 percent of
costs, private insurers cover only 20.8 percent of
the costs of addiction treatment, and the private
share has been decreasing. Instead, public
spending accounts for 79.2 percent of the costs
of addiction treatment in the United States.3
This skewing of services to populations
dependent on public resources is in part a result
of our failure to prevent and treat this disease.
Public spending also has concentrated available
resources for treatment in non-residential
services operated outside of the mainstream
health care system. In both public and private
plans, insurance coverage for addiction care has
been limited in the range of covered services.4
National data indicate that people in need of
help for addiction largely choose to turn to a
health professional; however, only 5.7 percent of
referrals to addiction treatment come from
health professionals. The largest share of
referrals— 44.3 percent— comes from the criminal
justice system,5 demonstrating our nation's
attention to the social consequences of addiction
rather than to prevention and treatment of the
disease. Even those who are referred to
treatment may face long waits for admission and
the longer the wait the less likely patients are to
enter or complete treatment.6
Only 42. 1 percent of those receiving treatment
for addiction involving alcohol or drugs other
than nicotine complete their course of care.7
The highest treatment completion rates are from
venues to which there are the least referrals-
residential treatment; the lowest treatment
Among current smokers who tried to quit in the past
year and former smokers who successfully quit in the
past two years.
f In the form of counseling or smoking cessation
medications.
completion rates are from venues to which there
are the most referrals-non-residential
treatment.8
A range of factors contribute to these spending,
referral and service delivery patterns that
account for the treatment gap, including a
misunderstanding of the disease of addiction, a
lack of appropriate disease staging and treatment
services,1 negative public attitudes and behavior
toward those with the disease, privacy concerns,
cost, lack of information on how to get help,
limited availability of services including a lack
of trained addiction physician specialists,
insufficient social support, conflicting time
commitments, negative perceptions of the
treatment process and legal barriers. Certain
populations with addiction, including those with
co-occurring health conditions, pregnant and
parenting women, adolescents, older adults, the
homeless, veterans and those in active duty
military, individuals living in rural areas and
Native Americans, face additional barriers.
This chapter examines the disconnect between
those in need of treatment and those who receive
it. The fact that those who do receive some form
of treatment rarely receive quality, evidence-
based care is discussed in Chapter X.
1 See Chapter X.
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Most People in Need of Treatment
Do Not Receive It
In 2010, 15.9 percent of the U.S. population
ages 12 and older-40.3 million people-met
diagnostic criteria for addiction. Although
some treatment providers are beginning to
address the disease of addiction
comprehensively, including all involved
substances, no single national data source exists
to compare the proportion of the population in
need of addiction treatment' involving any
addictive substance (including nicotine) to the
proportion that receives such treatment. CASA
Columbia's analysis of the treatment gap in the
following discussion, therefore, is based on
available data and limited to the 9.1 percent
(23.2 million) whose addiction involves alcohol
or other drugs excluding nicotine. i 9
CASA Columbia's analysis indicates that only
one in 10 (10.9 percent, 2.5 million) of those in
need of addiction treatment (excluding nicotine)
receive it, leaving a treatment gap of 20.7
million individuals. The proportion of
individuals in need of addiction treatment who
actually receive it has changed little since 2002,
when 9.8 percent of those in need received it.10
This is in stark contrast to the much smaller
treatment gaps that exist for other major health
conditions including hypertension, diabetes and
major depression.5 11
(Figure 7 A)
Figure 7. A
Individuals with Select Medical Conditions
Who Receive Treatment
Hypertension1
Diabetes2
Major
Depression3
Addiction3
(excluding
Nicotine*)
1 Ages 18 and older; Ostchega, Y., Yoon, S.S., Hughes, J. & Louis, T.
(2008).
2 All ages; Centers for Disease Control and Prevention. (201 1).
3 Ages 1 2 and older; CASA Columbia analysis of The National Survey
on Drug Use and Health (NSDUH), 201 0
* Due to data limitations.
Those meeting criteria for addiction include
individuals who met the Nicotine Dependence
Syndrome Scale (NDSS) criteria for past month
nicotine dependence, or the DSM-IV clinical
diagnostic criteria for past year alcohol and/or other
drug abuse or dependence. This estimate excludes
the institutionalized population, for which rates of
addiction are higher.
' Those in need of treatment are defined not only as
those who met DSM-IV diagnostic criteria for past
year alcohol and/or other drug abuse or dependence,
but also those who have received formal treatment
for addiction involving alcohol and/or other drugs in
the past year. Due to data limitations, individuals in
need of treatment for addiction involving nicotine are
not included in this analysis.
* Another nine percent (22.9 million) of the
population has addiction involving nicotine; 2.7
percent of the population (7.0 million) has addiction
involving multiple substances, including alcohol,
illicit drugs, controlled prescription drugs and/or
nicotine.
s For this comparison, CASA Columbia examined the
referenced national survey data to determine the
proportion of the population with each disease— those
with diagnosed or undiagnosed hypertension (59.3
million); those with diagnosed or undiagnosed
diabetes (25.8 million); those who met clinical
criteria for a major depressive episode in the past
year and/or received professional treatment (saw a
doctor, received medication, some combination
thereof) (22.4 million); and those who met clinical
criteria for addiction involving alcohol or other drugs
excluding nicotine in the past year and/or received
professional treatment for alcohol and/or other drugs
in the past year (23.2 million)— who received
treatment.
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Other national data indicate that, in 2010 among
smokers age 18 and older, 68.8 percent tried to
stop smoking* but only 31.7 percent of those
who tried to stop received some type of smoking
cessation service (psychosocial or
pharmaceutical treatment).^ 12
Variations in the Treatment Gap by
Primary Substance Involved
In 2010, 7.4 percent of the population needed
treatment for addiction involving alcohol* and
3.1 percent needed treatment for addiction
involving another drug (excluding nicotine);5 1.3
percent of the total population needed treatment
for addiction involving multiple substances,
excluding nicotine." While considerably more
people needed treatment for addiction involving
alcohol (18.7 million) compared to those
needing treatment for addiction involving an
illicit or controlled prescription drug (7.9
million) or multiple substances (3.4 million),11 13
they were less likely to receive it:
• 8.8 percent (1.7 million) of those in need of
treatment for addiction involving alcohol
received it, leaving a treatment gap of 17.1
million people;
The source of these data does not present the
proportion of the sample that smoked, just the
proportion of smokers that tried to quit.
' Among current smokers who tried to quit in the past
year and former smokers who successfully quit in the
past two years. Trend data are not available for these
measures.
* 18.1 percent of these individuals also needed
treatment for addiction involving other drugs.
§ 43.1 percent of these individuals also needed
treatment for addiction involving other drugs,
excluding nicotine.
The 7.4 percent of those needing treatment for
addiction involving alcohol and the 3.1 percent
needing treatment for addiction involving other drugs
overlap with the category needing treatment for
multiple substances. Looking at mutually exclusive
categories, 6.0 percent needed treatment for addiction
involving alcohol only and 1.8 percent needed
treatment for addiction involving other drugs
(excluding nicotine) only.
1 f Individuals in need of treatment for addiction
involving multiple substances also are included in the
other two categories.
19.9 percent (1.6 million) of those in need of
treatment for addiction involving another
drug (excluding nicotine) received it,
leaving a treatment gap of 6.3 million
people; and
28.5 percent (1.0 million) of those in need of
treatment for addiction involving multiple
substances (excluding nicotine) received it,
leaving a treatment gap of 2.4 million
people.14 (Figure 7.B)
Figure 7.B
The Treatment Gap:
Need for Addiction Treatment
and Receipt of Needed Services
(Excluding Nicotine), 2010
18.7M
I Need for Treatment
i Receipt of Treatment
7.9M
1.6M
3.4M
1.0M
Alcohol
Other Drugs
Multiple Substances
Note: Individuals who need and/or receive treatment for addiction
involving multiple substances also are included in the other two
categories.
Source: CASA Columbia analysis of The National Survey on Drug
Use and Health (NSDUH), 2010.
Of the 3 1 .7 percent of those ages 1 8 and older
who wanted to stop smoking in 2010, 5.9
percent received cessation counseling** and 30.0
percent received medications;55 4.3 percent
received both.15
++ 3. 1 percent used a telephone quitline, 2.6 percent
received one-on-one counseling and 2.4 percent were
involved in a stop smoking clinic, class or support
group.
§§ 14.6 percent used the nicotine patch, 1 1.2 percent
used the medication varenicline, 8.9 percent used the
nicotine gum or lozenge, 3.2 percent used the
medication bupropion and 1 .0 percent used the
nicotine spray/ inhaler.
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Variations in the Treatment Gap by Key
Patient Characteristics
The addiction treatment gap is substantial across
all demographic groups, with the greatest need
among adolescents, young adults and
Hispanics.16
Gender. In 20 1 0, twice as many males as
females were in need of addiction treatment
(12.2 percent vs. 6.2 percent).17 That year:
• 10.5 percent of males in need of treatment
received it, leaving a treatment gap of 13.5
million; and
• 11.7 percent of females in need of treatment
received it, leaving a treatment gap of 7.2
million.18
Although more males than females had
addiction involving nicotine in 2010 (9.9 percent
vs. 8.2 percent),19 more female than male
smokers were interested in quitting (70.7 percent
vs. 67.3 percent) and treatment was more
prevalent among females than among males
(35.1 percent vs. 28.8 percent).20
Age. In 2010, young people ages 18 to 25 were
the most likely of all age groups to need
addiction treatment:
• 7.5 percent of teens ages 12 to 17 and 20.5
percent of young adults ages 1 8 to 25 were
in need of treatment (15.1 percent of all 12
to 25 year olds) but only 1 . 1 percent of all
12 to 25 year olds received it,* leaving a
treatment gap of 8.2 million; and
• 7.4 percent of adults ages 26 and older were
in need of treatment but only 1.0 percent
received it, leaving a treatment gap of 12.5
million.21
Although more 18- to 25-year olds than adults
ages 26 and older had addiction involving
nicotine (10.4 percent vs. 9.7 percent) in 20 10,22
those ages 26 and older^ were more likely to be
interested in quitting, and smoking cessation
treatment was higher among those ages 25 and
older (29.4 percent of 25- to 44-year olds; 42.3
percent of 45-to 64-year olds; and 35.9 percent
of those ages 65 and older) than among 18- to
24-year olds (15.8 percent).23
Race/Ethnicity. Similar to racial/ethnic
disparities that have been found for other health
conditions,24 Hispanics were slightly likelier
than white or black people to need addiction
treatment (10.1 percent vs. 9.3 percent and 8.8
percent, respectively) but less likely to receive it
in2010:25
• 7.0 percent of Hispanics in need of treatment
received it, leaving a treatment gap of 3.5
million;
• 11.7 percent of whites in need of treatment
received it, leaving a treatment gap of 13.9
million; and
• 11.9 percent of blacks in need of treatment
received it, leaving a treatment gap of 2.4
million/26
Whites were likelier than blacks or Hispanics to
have addiction involving nicotine (10.9 percent
vs. 6.9 percent and 4.2 percent, respectively),27
but adult black smokers were likelier than adult
white and Hispanic smokers to be interested in
quitting in 2010 (75.6 percent vs. 69.1 percent
and 61.0 percent, respectively). White smokers,
however, were likelier to use smoking cessation
treatments than black or Hispanic smokers (36.1
percent vs. 21.6 percent and 15.9 percent,
respectively).28 Other research supports the
1 Interest in quitting was higher among adults ages 25
to 44 (72.5 percent) and ages 45 to 64 (69.0 percent)
relative to those ages 18 to 24 (66.7 percent); older
adults ages 65 and older were the least interested in
quitting (53.8 percent).
* A recent study found that black and Hispanic
adolescents are significantly less likely to receive
addiction treatment relative to white adolescents.
The sample sizes for those who received needed
treatment is too small to report statistically reliable
data for 12- to 17-year olds and 18- to 25-year olds
separately.
-135-
finding that black and Hispanic smokers are less
likely than white smokers to use smoking
cessation interventions such as nicotine
replacement therapy (NRT) and other
pharmaceutical therapies.29
Special Populations. The need for addiction
treatment is disproportionately higher for
individuals with co-occurring mental health
disorders, for individuals involved in the justice
system and for members of the military,
including veterans, returning from active combat
in Iraq and Afghanistan:
• In 2010, one in five (20.7 percent) non-
institutionalized individuals ages 1 8 and
older* with a diagnosed mental health
disorder' were in need of addiction
treatment (relative to 6.3 percent of those
without a diagnosed mental health disorder);
14.2 percent of those in need of addiction
treatment received it, leaving a treatment
gap of 8.5 million adults with co-occurring
addiction and mental health disorders.* 30 In
2010, only 37.6 percent of facilities
nationwide that provided addiction treatment
services offered services specific to patients
with co-occurring addiction and mental
health disorders.31
• In 20 1 0, adults with a mental illness were
more than 1.5 times as likely as those
without a mental illness to have smoked
cigarettes in the past year (41.3 percent vs.
Comparable data on those with mental health
disorders are not available for those ages 12-17.
1 And/or a reported major depressive episode.
* Research indicates that young people with co-
occurring conditions are more easily identified as
needing treatment than those with addiction only.
One study found that unmet treatment need (i.e., the
treatment gap) was greatest for teens with addiction
(37 percent) compared to a relatively lower treatment
gap of 23 percent among those with a psychiatric
disorder only and 19 percent among those with co-
occurring disorders. Other research confirms that
rates of addiction treatment are approximately three
times higher for adolescent illicit drug users who
report having received mental health treatment in the
past 12 months compared to those who have not
received mental health treatment.
25. 1 percent). Even though patients with
mental health disorders are likelier to
smoke33 and about as likely to want to quit
smoking as smokers in the general
population,34 research suggests that smoking
cessation services for these patients are
§ 35
rare.
• In 2010, nearly half (46.8 percent) of
individuals who were arrested or booked in
the past year, but not incarcerated at the time
of the survey, were in need of addiction
treatment (relative to 8.0 percent of those
who had not been arrested or booked in the
past year); 27.9 percent of those in need of
treatment received it, leaving a treatment
gap of 2.5 million individuals." 36 In 2010,
only 26.8 percent of facilities nationwide
that provided addiction treatment services11
offered services specific to patients involved
in the criminal justice system.37 Among
inmates, only 1 1.2 percent receive
treatment.
• Individuals involved in the justice system
also are likelier than the general population
to smoke39 but are less likely to receive
tobacco cessation services.40 One survey of
500 correctional facilities**-- including jails,
prisons and juvenile facilities— found that 80
percent reported that their facilities had no
tobacco cessation programs at all.41
• In 2005, of veterans from the military
operations in Iraq and Afghanistan who
sought health care from the Department of
Veterans Affairs (VA), 40 percent screened
positive for risky alcohol use and 22 percent
§ Based on research documenting health care
practice; national data on the use of smoking
cessation treatments in this population are not
available.
" Comparable treatment admission data from the
Treatment Episode Data Set (TEDS), described on
page 141 and in Appendix A, are not available for
this population.
n Excluding facilities such as jails, prisons or other
organizations that treat incarcerated individuals
exclusively.
tJ Accredited by the National Commission
on Correctional Health Care.
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screened positive for a possible addiction
involving alcohol* However, of those who
screened positive for risky alcohol use, only
3 1 percent were advised in the past year to
drink less or stop drinking; 4 1 percent of
those with a possible addiction involving
alcohol were given such advice.42 Another
study found that 1 1.8 percent of soldiers
who returned from Iraq reported risky
alcohol use but only 0.2 percent were
referred to treatment and only 21.6 percent
of those who were referred were seen within
90 days.43 And although the Handbook on
Uniform Mental Health Services requires
access to opioid maintenance therapy, fewer
than one in five veterans diagnosed with
addiction involving opioids receive this kind
of therapy on an ongoing basis.44
Regional Variations in the Treatment Gap
Current national data on regional differences in
the proportion of individuals in need of
addiction treatment are not available. ' However,
other research indicates that the disparity
between the number of people who need
addiction treatment and the number who receive
it varies substantially among states and regions
of the country,45 with southern and southwestern
states having the largest estimated treatment
gaps in the nation and the northeast having the
smallest estimated treatment gap.46
Although reasons for these geographical
differences in the treatment gap are not well
understood,47 possible explanations include
variations among states in funding of treatment
services, including differences in coverage of the
costs of these services in state managed care
systems.48 One study found that only 21 percent
of the variation among states in the percent who
receive treatment was associated with variations
Based on scores on a version of the AUDIT
instrument (see Appendix H). Risky drinking was
defined as an AUDIT-C score of four or higher for
men and three or higher for women. Addiction was
defined as an AUDIT-C score of four or higher for
women and six or higher for men.
' Public access NSDUH files have not contained
geographic variables since 1998.
in the prevalence of addiction; the rest of the
variation is attributable to these other factors.49
Sources of Funding for Addiction
Treatment
Spending on addiction treatment totaled an
estimated $28.0 billion in 2010. Whereas
private payers (including private insurers and
self-payers) are responsible for 55.6 percent
($ 1 .4 trillion) of medical expenditures in the
U.S., they are responsible for only 20.8 percent
($5.8 billion) of addiction treatment spending.50
Public payers picked up the tab for 79.2 percent
($22.2 billion) of expenses for addiction
treatment, with state and local governments
paying for 44.8 percent ($12.6 billion) and the
federal government paying for 34.4 percent
($9.6 billion).51 (Figures 7.C)
The concentration of spending for addiction
treatment in public programs suggests that
insurance across the board does not adequately
cover costs of intervention and treatment, with
costly health and social consequences falling to
government programs. National data* indicate
that those with private insurance are three to six
times less likely than those with public insurance
to receive specialty addiction treatment.5 52
1 From a study examining data from the 2002-2007
editions of the NSDUH. It is not possible to
determine from these data why treatment access
differed based on insurance type since the study
could not take into account important factors such as
individual characteristics and circumstances that may
relate both to type of insurance and likelihood of
treatment access (e.g., symptom severity, SES).
§ Defined in the study as treatment received in
hospital inpatient units, outpatient and residential
addiction treatment facilities, mental health facilities
and methadone maintenance facilities. Services
provided by private physicians (including
psychiatrists), independent practice mental health
practitioners, clergy, in prisons/jails and by self-help
groups are not included in the definition of treatment.
Those with no insurance are almost twice as likely as
those with private insurance to receive specialty
treatment.
-137-
Figure 7.C
Public vs Private Spending
Medical Care
Addiction Treatment
Public
44.4%
($1.1 T).
Private
55.6%
($1.4T)
Public
79.2%
($22.2 B)
Private
20.8%
($5.8 B)
Source: CASA Columbia (2012) analysis of the National Expenditures for Mental Health Services &
Substance Abuse Treatment 1986-2005 (Table A.1) SAMHSA Spending Estimates Project, 2010; CMS Office
of the Actuary, National Health Statistics Group with our estimated dollar updates.
Privately-Funded Treatment
In 2010, 20.8 percent ($5.8 billion) of addiction
treatment expenditures came from private
sources. Private spending includes:
• 56.6 percent ($3.3 billion) from private
health insurance;
• 30.5 percent ($1.8 billion) from self-pay by
patients; and
• 12.9 percent ($0.8 billion) from other private
sources, such as charitable donations and
charity care/fee waivers.53 (Figure 7.D)
Publicly-Funded Treatment
In 2010 79.2 percent ($22.2 billion) in addiction
treatment expenditures came from public
sources. Public spending includes:
• 45.3 percent ($10.1 billion) from state and
local government non-Medicaid sources;
• 26.3 percent ($5.9 billion) from Medicaid;
Figure 7.D
Components of Private Addiction
Treatment Spending (Total $5.8B)
Other Private.
Sources
12.9% ($0.8B)
Self-Pay
30.5%($1.8B).
Private Health
Insurance
56.6% ($3.3B)
Source: CASA Columbia analysis of the National Expenditures for Mental
Health Services & Substance Abuse Treatment 1986-2005. (2012).
19.9 percent ($4.4 billion) from other
federal funds such as block grants to states;
and
8.5 percent ($1.9 billion) from Medicare.* 54
(Figure 7.E)
Medicaid and Medicare are government programs
with state and federal contributions. Therefore, the
estimates reported in the federal, state and local
categories are exclusive of the estimates of public
funds spent through Medicare and Medicaid
programs.
-138-
Figure 7.E
Components of Public Addiction
Treatment Spending (Total $22.2B)
Medicare
8.5% ($1 .9B)
Other Federal
19.9% ($4.4B)
Medicaid
26.3% ($5.9B)
Other State &
Local
45.3%
($10.1B)
Source: CASA Columbia analysis of the National Expenditures
for Mental Health Services & Substance Abuse Treatment 1986-
2005. (2012).
Trends in Spending on Addiction
Treatment
Expenditures by Providers and
Types of Services
Most expenditures for addiction
treatment are to non-hospital based
providers offering outpatient services.
Providers. Treatment providers
whose primary role is addiction
treatment account for 61.7 percent
($17.3 billion) of the total spending on
addiction treatment ($28.0 billion).57
These expenditures include:
• 43.4 percent ($12.2 billion) by
specialty addiction treatment
centers;
• 12.8 percent ($3.6 billion) by specialty units
in general hospitals; and
Between 1986 and 2010, direct spending on
addiction treatment increased from $9. 1 billion
to an estimated $28.0 billion. In constant
dollars, direct spending on addiction treatment
nearly doubled during this period, while the
portion of direct addiction treatment paid by
private sources fell from 39.8 percent to 20.8
percent and the portion paid by public sources
rose from 60.2 percent to 79.2 percent. While
there also was a shift from private to public
payment of medical care expenditures during
this period, the shift was far less pronounced;
private source payment of medical expenditures
dropped from 61.2 percent in 1986 to 55.7
percent in 2005 while public source payment
rose from 38.8 percent to 44.3 percent.55
/ was not able to get help until I got myself into
the criminal justice system and was then placed
into treatment as a condition of parole. I tried
many times to get help for my addiction but due
to the lack of insurance and money, was
denied.56
• 5.5 percent ($1.5 billion) by specialty
hospitals.58
The remaining expenditures (38.3 percent, $10.7
billion) are accounted for by facilities and
individuals that have another primary mission
but also provide addiction-related services,
including:
• 8.8 percent ($2.5 billion) by specialty mental
health centers;
• 7.9 percent ($2.2 billion) by health
professionals other than physicians such as
counselors, social workers and
psychologists;
• 6.8 percent ($1.9 billion) by general hospital
non-specialty units such as detoxification,
when a patient with addiction is admitted via
the emergency room;
—Respondent to CASA Columbia's
Survey of Individuals in
Long-Term Recovery
Not considered to be addiction treatment.
-139-
• 6.7 percent ($1.9 billion) in
insurance administration;
• 6.3 percent ($1.8 billion) by
physicians;
• 1 .2 percent ($0.4 billion) by
nursing homes and home health
care providers; and
• 0.6 percent ($0.2 billion) in retail
prescription drugs.59 (Figure 7.F)
Services. Total addiction treatment
spending in 2010 ($28.0 billion)
included:
• 92.7 percent ($25.9 billion) for
services, including:
> 48.3 percent ($13.5 billion)
for outpatient services (non-
hospital, 38.4 percent, $10.8
billion and hospital, 9.8
percent, $2.8 billion);
> 27.9 percent ($7.8 billion) for
residential (non-hospital
inpatient) services; and
> 16.5 percent ($4.6 billion) for
inpatient hospital services;
• 6.7 percent ($1.9 billion) in
insurance administration fees; and
• 0.6 percent ($0.2 billion) for retail
prescription drugs.60 (Figure 7.G)
Figure 7.F
Addiction Treatment and
Related Services Spending*
Physicians
6.3%
($1.8B)_
Insurance
rtUi 1 1 11 llbu dllUl 1
6.7%
Nursing
Homes/Home;
Health Care
Providers
\ 1 .2%
\f$0.4B)
Retail
; Prescription
Drugs
0.6%
($0.2B)
/ Specialty Mental
/ Health Centers
/ 8.8%
($1.9B)
^\ ($2.5B)
General Hospital
Non-Specialty
6.8%
($1.9B)
/ B Specialty
Other Health _
Professionals
7.9%
($2.2B)
/ Addiction
/ H Centers
($12.2B)
Specialty --'
Hospitals
5.5%
($1.5B) Specialty Units J
in General
Hospitals
12.8%
($3.6B)
* The combination of spending by provider type and spending related to other
categories such as retail prescription drugs and insurance administration is a
function of the way the national expenditure data are presented by SAMHSA.
Source: CASA Columbia analysis of the National Expenditures for Mental Health
Services & Substance Abuse Treatment 1986-2005. (2012).
Figure 7.G
Spending by Service (Total $28.0B)
Insurance
Arlminktmtinn j.
Retail
Prescription
Drugs
0.6% ($0.2B)
6.7% ($1 .9B) s<T
Inpatient / \
Hospital yf \
16.5% ($4.6B)^^/ \
(
N. Outpatient
\^48.3% ($13.5B)
Residential \
27.9% ($7.8B)_^^
U
Source: CASA Columbia analysis of the National Expenditures for Mental
Health Services & Substance Abuse Treatment 1986-2005. (2012).
-140-
Treatment Admissions
There are no national data on individuals who
receive addiction treatment in the U.S.; the
national data that are available represent
admissions to treatment facilities for addiction
involving alcohol or other drugs (excluding
nicotine) for the 79.2 percent of addiction
treatment funding that comes from public
sources, although some of these facilities also
may receive private funding/
While some addiction treatment programs may
address nicotine, they do not report these services in
their treatment admission data.
' These analyses are based on data from the
Treatment Episode Data Set (TEDS), a national
database of information on the demographic and
addiction characteristics of admissions to and
discharges from addiction treatment facilities,
routinely collected by each state substance abuse
agency and submitted to the Substance Abuse and
Mental Health Services Administration (SAMHSA).
TEDS collects information about the beginning and
termination of treatment episodes; multiple episodes
of treatment for the same client are counted
separately. The 2009 TEDS data are based on
information on the demographic and substance use
characteristics of the approximately 1.5 million
annual admissions to alcohol and other drug
addiction treatment facilities (excluding
detoxification), among those ages 12 and older, that
report to individual state substance abuse agency data
systems. The TEDS attempts to include all
admissions to providers receiving public funding;
however, because each state or jurisdiction decides
the TEDS eligibility of a provider, there is no
independent check on the actual sources of funding.
Although SAMHSA requests submission of TEDS
data on all admissions to any publicly funded
treatment facility, reporting in some state agencies is
structured so that only patients treated with public
funds are included in the TEDS. The number of
patients in these facilities whose treatment is not
publicly funded is unknown. Because the scope of
facilities included in the TEDS is affected by
differences in state licensure, certification,
accreditation and disbursement of public funds, the
TEDS, while comprising a significant proportion of
all admissions to addiction treatment, does not
include all admissions. (See Appendix A for more
information about TEDS.) It is important to note that
CAS A Columbia's analyses of TEDS data exclude
detoxification services in calculating rates of
P
E
R
C
E
N
T
In 2009/ there were 1.5 million admissions to
publicly-funded addiction treatment facilities.5
More than half (55.6 percent) of the admissions
were for addiction involving multiple
substances. For 38.6 percent of the admissions,
alcohol was the primary substance of addiction,
compared with 29.0 percent for illicit drugs
other than marijuana, 22.4 percent for marijuana
and 7.9 percent for controlled prescription
drugs.61 (Figure 7.H)
Figure 7.H
Admissions to Publicly-Funded Addiction
Treatment by Primary Substance
and Multiple Substances
55.6
38.6
29.0
22.4
i
n
7.9
1 1
Alcohol
Marijuana
Prescription
Drugs
Illicit Drugs
Other Than
Marijuana
Note: Admissions for addiction involving multiple substances
also are included in the other categories.
Source: CASA Columbia analysis of The Treatment Episode
Data Set (TEDS), 2009.
Multiple
Substances
Admissions to publicly-funded addiction
treatment reflect greater attention to addiction
involving illicit drugs other than marijuana and
multiple substances relative to the prevalence of
addiction involving these substances in the
population.
62
admissions to addiction treatment; therefore, data
reported in this report may differ from those
published in TEDS reports.
* The most recent available data.
§ Included in the TEDS database.
Of those needing addiction treatment, 80.7 percent
involve alcohol, 18.9 percent involve marijuana, 10.3
percent involve controlled prescription drugs and 7.0
percent involve illicit drugs other than marijuana;
14.6 percent involve multiple substances.
(Categories are not mutually exclusive.)
-141-
Between 2002 and 2009, treatment
admissions to publicly-funded addiction
treatment increased by 7.0 percent (from
1.4 million to 1.5 million). During that
time, admissions where prescription
drugs were the primary substances of
addiction increased the most— by 92.7
percent; admissions where marijuana was
the primary substance of addiction
increased by 13.1 percent. At the same
time, admissions where illicit drugs other
than marijuana were the primary
substances of addiction declined by 1 1.0
percent and admissions where alcohol
was the primary substance of addiction
declined by 6.5 percent. Between 2002
and 2009, admissions for addiction
involving multiple substances declined
by 1.2 percent.63 (Figure 7.1)
Treatment Referrals and
Venues
CAS A Columbia's NABAS found that
46.8 percent of respondents would turn to
a health professional— such as their
physician (27.8 percent), a health
professional other than their primary care
physician (19.7 percent) or a mental
health professional (9.2 percent) f~ if
someone close to them needed help for
addiction.64 (Figure 7. J)
Figure 7.1
Trends in Admissions to Publicly-Funded
Addiction Treatment by Substance, 2002-2009
70.0
60.0
p
50.0
E
R
40.0
C
E
30.0
N
20.0
T
10.0
0.0
•Multiple
Substances
• Alcohol
Illicit Drugs other
than Marijuana
• Marijuana
2002 2004 2006 2008 2009
Prescription
Drugs
Source: CASA Columbia analysis of The Treatment Episode Data
Set (TEDS), 2009.
Figure 7.J
Where People Would Turn for Information/Help
with Addiction for Someone Close to Them
Primary Care Physician
1 27.8
Mutual Support Program
1 ?1 0
Other Health Professional
I 19.7
P
"Do Research/Look It Up"
I 18.8
E
Addiction Treatment Center
I 11.0
R
C
Friend/Family Member
I I 10.7
E
N
T
Church/Clergy or Relgious/Spiritual Leader
ZZI 9-8
Mental Health Professional
I 9.2
Addiction Hotline/Helpline
I 7.2
Source: CASA Columbia National Addiction Belief and Attitude
Survey (NABAS), 2008.
Not including mental health professionals.
' Some respondents chose more than one response so
the 46.8 percent reflects those who chose either one
of these health professionals.
-142-
Another national survey found that 65 percent of
adults would turn to a health care provider for a
problem involving alcohol.65 Despite these
findings, the smallest proportion of referrals to
publicly-funded addiction treatment comes from
health professionals.66
Of all the admissions to publicly-funded
addiction treatment in 2009, 44.3 percent were
referred by the criminal justice system. One-
quarter (25.3 percent) of referrals came from
individuals, including concerned family
members, friends and the self-referred;f 12.1
percent were referred by community sources
such as social welfare organizations, religious
organizations and mutual support programs;*
10.6 percent were referred by addiction
treatment providers5* for additional treatment and
Referrals from the criminal justice system include
referrals from any police official, judge, prosecutor,
probation officer or other person affiliated with a
federal, state or county judicial system. This
category also includes referrals by a court for
DWI/DUI, patients referred in lieu of or for deferred
prosecution, during pretrial release, before or after
official adjudication, as well as referrals of those on
pre -parole, pre-release, work or home furlough or
Treatment Alternatives for Safe Communities
(TASC).
' Separate data on each of these categories are not
available in the TEDS dataset.
* Community sources of referral also include
government agencies that provide aid in the areas of
poverty relief, unemployment, shelter or social
welfare and referrals from defense attorneys.
According to the TEDS data, defense attorneys are
not included in the criminal justice system category;
prosecutors are included in that category. These
community referral categories cannot be examined
separately in the TEDS dataset.
§ Addiction service providers are those programs,
clinics or health care providers whose principal
objective is treating patients with addiction, or where
a program's services are related to substance use
prevention or education. TEDS distinguishes
between transfers within a single, continuous
treatment episode and the initiation of a new
treatment episode but, because TEDS relies on state
administrative systems that appear to differ greatly in
their ability to distinguish transfers within a
continuous treatment episode from the initiation of a
new treatment episode, some transfers may be
reported by TEDS as new treatment episodes.
5.7 percent were referred by a health care
provider. Very few treatment referrals came
from schools (1.4 percent)1' or from employers
or Employee Assistance Programs (0.6
percent).67 (Figure l.K^)
Figure 7.K
Sources of Referral to Publicly-Funded
Addiction* Treatment
Criminal Justice System
1 44.3
Individuals
1 25.3
P
E
Community Sources
1 12.1
R
C
E
Addiction Treatment Providers
I 10.6
Health Care Providers
■ 5.7
N
T
Schools
] 1.4
Employers
0.6
* Excluding nicotine.
Source: CASA Columbia analysis of The Treatment Episode
Data Set (TEDS), 2009.
Given that addiction is a medical disease
requiring the intervention of trained medical
professionals and the high prevalence of this
disease in the general population,55 the fact that
only 5.7 percent of treatment admissions are
referred by health professionals highlights the
extent to which health professionals fail to
address this disease in their practice. The fact
that the largest proportion of referrals to
addiction treatment comes from the criminal
justice system further underscores how
extensively we neglect to address addiction until
the consequences are too dire to ignore.68 The
Referrals to treatment programs from health care
providers include those from physicians (including
psychiatrists) or other licensed health professionals,
or from a general hospital, psychiatric hospital,
mental health program or nursing home.
(t Including a school principal, counselor, teacher,
student assistance program (SAP), the school system
or an educational agency.
" These data are from the TEDS dataset.
Comparable data on referral to treatment for nicotine
addiction (smoking cessation) are not available. The
data reported here do not include referrals to
detoxification programs.
§§ See Chapters II and III.
-143-
separation of addiction treatment from
mainstream health care is demonstrated further
by the fact that most treatment venues are not
licensed health care institutions.69
(See Chapter IX.)
Available data on treatment venues to which
referrals are made distinguish between intensive
and non-intensive services provided in non-
residential settings and between short- and
longer-term services provided in residential
70
settings:
• Non-residential services include individual,
family, group and/or pharmaceutical
therapies provided on an ambulatory or
outpatient basis. Intensive services are those
that last at least two or more hours per day
for three or more days per week.
• Residential services include addiction
treatment provided in a non-hospital setting,
and 24-hour per day medical care in a
hospital facility that includes addiction
treatment. Short-term services include those
that last for 30 days or less and longer-terms
services are those that last for more than 30
days.
There are no data available to match the need for
specific services with referrals to specific
treatment venues. Although referrals to
treatment primarily come when addiction has
advanced to the point of serious social
consequences (e.g., the criminal justice system)
and often involve co-occurring health
conditions, in 2009, the majority of the 1.5
million treatment admissions were to non-
intensive and non-residential venues:71
• 63.3 percent were for non-intensive, non-
residential services;
• 14.6 percent were for intensive, non-
residential services;
• 11.9 percent were for short-term residential
services; and
• 10.2 percent were for longer-term residential
services.72 (Figure 7.L)
Figure 7.L
Admissions to Different Types of
Treatment Service Venues
p
E
R
63.3
C
E
N
14.6
11.9
10.2
T
I I
Non-
Intensive Non-
Short-Term
Longer-Term
Intensive/Non- Residential Residential Residential
Residential Services Services Services
Services
Source: CASA Columbia analysis of The Treatment Episode
Data Set (TEDS), 2009.
While most admissions regardless of referral
source are to non-residential venues (77.9
percent), certain referral sources are even likelier
than average to result in admissions to non-
residential services, including:
• schools (97.8 percent);
• the criminal justice system (85.5 percent);
• employers (84.0 percent); and
• community sources (79.3 percent).73
In contrast, while only 22.0 percent of treatment
admissions overall are referred to residential
treatment venues, 47.8 percent of those referred
by addiction treatment providers are to
residential treatment venues.74 (Table 7.1)
-144-
Table 7.1
Admissions to Different Types of Treatment Service Venues
by Source of Referral, 2009 (Percent)
Source oi
Non-
Intensive
Snort- 1 erm
Longer-
Relerral
Intensive
Non-
T» "J 4.' 1
Residential
Term
XT
Non-
Residential
Residential
Residential
Total
63.3
14.6
11.9
10.2
Criminal
69.7
15.8
6.3
8.1
Justice
System
Individual
61.0
13.7
14.2
11.1
Referrals
Community
62.3
17.0
11.2
9.6
Sources
Addiction
41.3
10.9
29.0
18.8
Treatment
Providers
Health Care
60.2
12.7
17.5
9.6
Providers
Schools
88.2
9.6
1.3
0.9
Employers
67.3
16.7
13.6
2.5
Treatment Completion
In 2008,* less than half (42.1 percent) of
discharges from addiction treatment services1
were of admissions in which treatment was
completed. * 75 The highest completion rates
were from venues to which there were the least
referrals:
• 14.8 percent of admissions were to short-
term residential services which had the
highest completion rate of 54.8 percent;
• 11.4 percent of admissions were to longer-
term residential treatment which had a
completion rate of 45.5 percent; and
• 73.8 percent of admissions were to non-
residential services which had the lowest
completion rate of 39.1 percent.7
(Figure 7.M)
Source: CASA analysis of The Treatment Episode Data Set (TEDS),
2009.
Figure 7.M
Percent of Treatment Admissions and
Completions by Different Types of
Treatment Service Venues, 2008
54.8
I Admissions
1 Completions
73.8
14.8
11.4
45.5
□
39.1
Short-Term Residential
Services
Longer-Term
Residential Services
Non-Residential
Services
Source: CASA Columbia analysis of The Treatment Episode
Data Set, Discharges (TEDS-D), 2008.
Most recent available data on discharges.
' Specifically, those that received state funds and
reported data to TEDS. Data include only those
discharges that could be linked to admission data in
the 2008 TEDS dataset. The general completion rate
among all discharges (regardless of whether they
were linked to admission data) was 42.1 percent.
* All parts of the treatment plan or program were
completed.
-145-
Of those discharges that did not represent a
completed treatment episode, 46.6 percent
dropped out of treatment, 25.9 percent were
transferred to another treatment service (whether
or not the patient attended that program is
unknown), 12.8 percent were terminated by the
program and 4.5 percent were incarcerated. The
remainder failed to complete treatment for some
other reason.* 77
Variations in Treatment Completion by
Source of Referral
Admissions to addiction treatment for which the
source of referral was an employer were the
most likely to complete treatment (57.2 percent
of admissions), followed by referrals from the
criminal justice system (48.1 percent).
Admissions referred by health care providers
and individual sources-including concerned
family members, friends and the self-referred-
were the least likely to complete treatment (34.6
percent and 33.9 percent of admissions,
respectively).78 Concern about potential loss of
a job or criminal sanctions might help account
for higher rates of treatment completion among
those referred by employers or the criminal
justice system. (Table 7.2)
Table 7.2
Treatment Completion by Source of Referral
Source of Referral
Percent
Total
42.1
Employers
57.2
Criminal Justice System
48.1
Addiction Treatment Providers
44.5
Schools
41.1
Community Sources
36.6
Health Care Providers
34.6
Individual Referrals
33.9
Source: The Treatment Episode Data Set (TEDS)
discharge data, 2008.
Variations in Treatment Completion by
Primary Substance Involved
Patients admitted to treatment with addiction
involving alcohol as the primary substance had
the highest rate of treatment completion (50.7
percent) compared with 39.3 percent involving
marijuana, 35.4 percent involving other illicit
drugs and 35.3 percent involving prescription
drugs. The treatment completion rate for
admissions involving multiple substances was
38.9 percent
79
Variations in Treatment Completion by Key
Patient Characteristics
Male patients admitted to treatment were likelier
than females to complete treatment (48.5 percent
vs. 42.6 percent of admissions). No significant
age-related differences in treatment completion
were found.80 With regard to racial/ethnic
differences in treatment completion, Hispanics
admitted to treatment were more likely to
complete treatment than were whites or blacks
(46.8 percent vs. 37.9 percent and 35.4 percent
of admissions, respectively).' 81
Link between Funding Source,
Type of Service Provided and
Treatment Completion
Individuals who are privately insured are
substantially less likely to enter addiction
treatment than those with public insurance.* 82
Publicly-funded admissions to addiction
treatment are likelier than privately-funded
admissions to be for more intensive services:
i.e., moving, illness or hospitalization, death, other
reason out of patient's control or the reason for
discharge is unknown or not recorded.
' Similarly, a study of patients receiving treatment for
addiction involving alcohol found that black patients
were less likely than white or Hispanic patients to
complete their treatment program, regardless of
whether they were enrolled in non-residential
treatment (17.5 percent vs. 26.7 percent and 29.7
percent, respectively) or residential treatment (30.7
percent vs. 46.1 percent and 42.9 percent,
respectively).
* Controlling for type of substance, severity of the
addiction, demographic characteristics, current health
status and whether the individual is a daily cigarette
smoker.
-146-
• intensive outpatient (25.9 percent vs. 15.1
percent),
• short-term residential (21.6 percent vs. 14. 1
percent), and
• longer-term residential (7.6 percent vs. 3.0
percent).83
Privately- funded admissions are likelier than
publicly-funded admissions to be to non-
intensive outpatient services (67.6 percent vs.
44.7 percent), have a higher rate of treatment
completion (53.7 percent vs. 42.9 percent) and
have a lower rate of transfer to another facility
(12.2 percent vs. 17.9 percent).84
Existing data do not provide an explanation for
these differences and no data are available on
treatment needs and outcomes by funding source
and type of service provided. Possible
contributing factors, however, might include that
privately-funded admissions are likelier to
involve less severe cases of addiction, those with
private resources may have greater access to
effective support services or quality care, or
those with private insurance may be less likely
to seek treatment perhaps due to the perceived
stigma.
Barriers Patients Face in Accessing
and Completing Addiction
Treatment
In addition to the limited private sector coverage
of addiction treatment and the lack of treatment
referrals from the health care system, many
other barriers stand in the way of individuals
accessing and completing addiction treatment.
These include: a misunderstanding of the
disease, negative public attitudes and behavior
toward those with the disease, privacy concerns,
cost, lack of information on how to get help,
limited availability of services including a lack
of physicians trained in addiction care,
insufficient social support, conflicting time
commitments, negative perceptions of the
treatment process and legal barriers. Other
factors having to do with treatment quality are
discussed in Chapter X. Rarely is there only one
obstacle to a person receiving needed
treatment.86
Although comparable national data for barriers
to accessing smoking cessation treatment are not
available, research indicates that barriers similar
to those facing individuals seeking addiction
treatment involving alcohol or other drugs stand
in the way of smokers accessing tobacco
cessation services.87
Misunderstanding of the Disease
One of the most frequently reported barriers to
accessing addiction treatment has been described
as patient denial.88 However, what is commonly
viewed as denial might also be characterized as
a misunderstanding of the disease. As is the
case for seeking treatment for other health
conditions such as diabetes, hypertension or
heart disease,89 most cases of denial that serve as
barriers to treatment access actually involve
cases in which a person with symptoms of
addiction does not recognize that he or she has a
treatable disease,90 underestimates the severity
of the disease91 or does not believe that the
symptoms can be allayed through treatment.92
Such feelings stem not only from a lack of
public awareness about the true nature of
addiction— that it is a brain disease that can be
treated effectively—but from the disease itself—
one effect of addictive substances on the brain is
that judgment, self-awareness and insight
become impaired.93 Continuing to misuse
substances despite the associated harms is a
defining symptom of the disease of addiction94
and in many cases results from the changes that
addictive substances produce in the structure and
function of the areas of the brain that control
judgment, decision making and behavioral
inhibition and control.95
In one survey of people with a history of
addiction in their families, 60 percent cited
denial as the biggest obstacle to getting help for
addiction.96 The majority (71.7 percent) of
respondents to CASA Columbia's NAB AS think
that a main reason why people with addiction do
not get the help they need is that they refuse to
admit to having a problem or that they do not
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want to quit.* 97 Another study found that
between eight and 1 6 percent of people who had
been assessed but had not entered treatment
cited some form of denial as the barrier. f 98
The most frequently-mentioned barrier to
accessing treatment for addiction involving
alcohol and drugs other than nicotine is not
being ready to stop using these substances.1 99 A
study of current smokers in Wisconsin found
that the main barriers to quitting that participants
reported were not being ready to stop smoking
because they enjoy it (79 percent), would crave
it (75 percent) or are afraid of losing the stress
relief associated with it (63 percent).100
One national survey found that among
respondents who needed8 but did not receive
treatment, only 3.3 percent of those with
addiction involving alcohol, 8.3 percent of those
with addiction involving another drug
(excluding nicotine) and 12.4 percent of those
with addiction involving multiple substances
(excluding nicotine) perceived a need for
treatment.101
Treatment providers also cite denial as the main
barrier to treatment access: CAS A Columbia's
survey of treatment providers in New York State
found that 85.5 percent of program directors and
84.9 percent of staff providers said that denial of
an addiction problem "very much" stands in the
way of people looking for needed addiction
102
treatment.
Misunderstanding of the disease of addiction
also is reflected in public policies and health
care practices that fail to integrate treatment for
Respondents were asked to select two or three
reasons from a list read to them by the interviewer.
' Eight percent of respondents believed their "drug
use is not causing any problems" while 16.1 percent
believed they "could handle their drug use on their
own."
* As reported in a national survey of individuals ages
12 and older who recognized they needed treatment,
made an effort to get treatment, but did not receive
treatment. These estimates are from combined
national data from 2006-2009.
§ Met clinical diagnostic criteria for addiction
involving alcohol or drugs other than nicotine.
all addictive substances including nicotine into
standard treatment protocols. (See Chapter X.)
Negative Public Attitudes and Behaviors
Toward People with Addiction
Related to widespread misunderstanding of the
disease of addiction is the stigma attached to it—
the well documented, strong disapproval of or
discrimination against those with the disease—
and the fear of repercussions which prevent
people with addiction from getting help.103
Although stigma is a subjective experience-
perceived disapproval by others and subsequent
embarrassment may or may not reflect a more
objective reality— there is a long history of
blaming and looking down on people with
addiction104 rather than sympathizing with them
as we do for those with other health conditions.
The fear of disapproval or rejection can derive
from an individual's own low self-esteem or
sense of shame about having addiction or it can
derive from a fear of abandonment by friends or
family because of the substance use itself, the
consequences that result or because of the
decision to pursue treatment.105
Twenty-nine percent of the respondents to
CASA Columbia's NABAS reported that the
main reason why people with substance-related
problems do not get the help they need is a fear
of social embarrassment or shame.106 Another
national survey found that two-thirds (67
percent) of the public believe that a stigma exists
toward people who have been treated for
addiction involving alcohol or other drugs." 107
A related study found that 80 percent of the
public believes that there is a stigma against
people with addiction involving alcohol and 5 1
percent believe this stigma is maintained even
after treatment or cessation of alcohol use.108
Smokers also face a stigma, particularly in light
of increasing anti-smoking policies and
awareness of the health risks of smoking and
exposure to environmental tobacco smoke.109
This survey excluded addiction involving nicotine.
Stigma was defined for respondents as "something
that detracts from the character or reputation of a
person; a mark of disgrace."
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One survey of New York City residents found
that 39 percent said that "Most people think less
of a person who smokes" and 21 percent said
that "Most people believe smoking is a sign of
personal failure."110
Over 40 percent (4 1 .4) of respondents to the
NABAS reported that discrimination against
people in recovery from addiction involving
nicotine, alcohol or prescription or illegal drugs
is a very (15.8 percent) or somewhat (25.6
percent) serious problem in their community;
51.0 percent of those who had their own history
of addiction thought it was a very (24.5 percent)
or somewhat (26.5 percent) serious problem.111
Thirty-eight percent of the respondents to the
NABAS reported that the main reason why
people with addiction do not get the help they
need is a fear of adverse consequences like
losing a job, getting expelled from school or
losing child custody. Treatment providers also
see this as a barrier to treatment access: CASA
Columbia's survey of treatment providers in
New York State found that a significant
proportion of the respondents said that the fear
that one will be discriminated against
"somewhat" (48.2 percent of program directors
and 5 1 .4 percent of staff providers) or "very
much" (39.8 percent of program directors and
30.4 percent of staff providers) stands in the way
of people looking for needed addiction
treatment, as does fear of losing one's job (96.3
percent of directors and 94.2 percent of staff
providers said this "somewhat" or "very much"
stands in the way of people looking for needed
treatment).112
Another recent study found that while there are
no significant differences in employment rates
between people with a history of addiction and
those without, those with a history of addiction
report significantly higher rates of involuntary
job loss. The analyses conducted for the study,
which controlled for other factors that predict
employment outcomes, suggest that employer
discrimination may be an important contributing
factor to job instability in this population. The
authors speculate that while the Americans with
Defined as effectively managing their disease.
Disabilities Act of 1990 is successful in
protecting those with a history of addiction from
experiencing discrimination in the hiring
process, it might be less successful in protecting
those people from job termination.113
Individuals with a lifetime diagnosis of
addiction involving alcohol are less likely to
access treatment or support services f if they
perceive that addiction carries a stigma.114
Respondents to the NABAS admit that they
would discriminate against people who have a
history of addiction, being less likely to hire
former smokers or those in recovery from
addiction involving alcohol or other drugs.115
• 53.6 percent of respondents said that they
would be less likely to hire a qualified
applicant upon learning that he or she is in
recovery from addiction involving illicit
drugs;
• 41.1 percent would be less likely to hire a
qualified applicant in recovery from
addiction involving controlled prescription
drugs;
• 27.9 percent would be less likely to hire a
qualified applicant in recovery from
addiction involving alcohol; and
• 6.6 percent would be less likely to hire a
qualified applicant who is a former
smoker.116
In comparison, 18.0 percent said they would be
less likely to hire a qualified applicant who had
been treated for depression, about nine percent
said that they would be less likely to hire a
qualified applicant who had been treated either
1 Defined in this study as including services delivered
in an inpatient ward, outpatient clinic, rehabilitation
program, halfway house, emergency room or crisis
center or by a private physician, psychiatrist,
psychologist, social worker or other professional;
alcohol or other drug detoxification; and self-
help/mutual support programs (e.g. AA) or social
services (family services or services delivered by an
employee assistance program or by clergy).
-149-
for obesity or heart disease and about five
percent said the same for diabetes, asthma or
cancer/ 117 (Figure 7.N)
Figure 7.N
Participants Reporting They Would Be Less Likely*
to Hire a Qualified Candidate in Recovery
from/Treated for Each Condition:
Addiction-Illicit Drugs
Addiction-Prescription Drugs
Addiction-Alcohol
Depression
Obesity
Heart Disease
Smoking
Diabetes
Asthma
Cancer
53.6
41.1
■ 27.9
I 18.0
9.4
9.2
I 6.6
5.4
4.8
4.7
* Among those who responded "somewhat less or much less likely1
Source: CASA Columbia National Addiction Belief and Attitude
Survey (NABAS), 2008.
Another study found that 43 percent of the
public would be less likely to vote for a
gubernatorial candidate who was in recovery
from addiction involving alcohol or other drugs
(excluding nicotine).
Perhaps because of the lingering view that
addiction results from lack of will power or self
control that can be remedied with a simple
change of mind, stigma and
discrimination against addicted
individuals are all too common.
Recent research finds that people
with addiction are seen as more
blameworthy and dangerous
compared to individuals with a
"mental" illness, and those with
a "mental" illness are viewed
more negatively than those with
a "physical" illness.
Consequently, those with
addiction are avoided more and
helped less.121 Research also
indicates that enhancing the
public's understanding of
addiction or mental health
disorders as having a
neurobiological basis relates to
increased public support for providing treatment
services to individuals with these conditions, but
has not yet translated into less of a stigma or
discrimination associated with these
conditions.
P
E
R
C
E
N
T
122
118
Discrimination against those with addiction is
manifested on the governmental and institutional
levels as well. Insurance companies generally
provide less coverage for addiction treatment
services than for other medical services.119
Although the passage of the Paul Wellstone and
Pete Domenici Mental Health Parity and
Addiction Equity Act (MHPAEA) of 2008, and
the subsequent 2010 Patient Protection and
Affordable Care Act, were significant
breakthroughs, the laws contain exemptions and
loopholes that may continue to limit access to
addiction treatment.1 120
The stigma associated with addiction is
compounded by its high rate of co-occurrence with
mental illness.
' For example, MHPAEA does not require health
insurance plans to offer coverage for mental health or
addiction treatment services, employers with fewer
than 50 employees are not covered by the law, and if
the projected cost increase is too high for health
Privacy Concerns
Because of negative public attitudes toward
addiction and the consequent potential for
stigma and discrimination, prospective patients
for addiction treatment may have concerns about
the extent to which their identity and the details
of their treatment will stay private and
confidential.123
Prospective patients sometimes believe that
providers violate patients' confidentiality.124
insurance plans (more than two percent in the first
year and more than one percent in subsequent years),
then insurance companies may request an exemption
from the law. Under the ACA, mental health and
addiction treatment services must be offered in
individual and small group health plans as part of
essential health benefits, but the scope of these
benefits will likely vary by state. See Chapter VIII
for a more complete discussion of health insurance
coverage for addiction prevention and treatment
services.
-150-
Privacy concerns are particularly acute in rural
populations where patients may fear a lack of
anonymity due to relatively smaller and more
close-knit communities.125
Another element of privacy concerns involves
the aversion of some individuals to key elements
of the therapeutic process— participating in
individual or group therapy where patients
discuss personal or intimate details with
therapists or with other patients.126 In one study
of individuals with addiction, 36.5 percent of
respondents said they do not like talking in
groups, 35.6 percent said they do not like to talk
about their personal lives with other people and
32. 1 percent said they do not like being asked
personal questions.127 In a study of risky alcohol
users, 50 percent cited a combination of
concerns about privacy, labeling, asking for help
and sharing problems as a reason for not seeking
1 28
treatment.
Cost*
Cost is one of the most frequently-reported and
long-standing barriers to receiving addiction
treatment.129 Approximately 50 million
Americans, or 16.3 percent of the United States
population, had no health insurance in 2010. 130
Twenty-nine million insured people are
underinsured' 131 perhaps prompting them to
postpone needed treatment. People who are
uninsured and underinsured not only have higher
rates of chronic, relapsing addiction,132 but also
generally receive less preventive care, are at
more advanced disease stages at the time of
diagnosis, receive less treatment for health
conditions and have higher mortality rates than
those with comprehensive coverage.133
A 2009 national survey found that nearly half
(49 percent) of U.S. adults feel that they would
not be able to afford treatment for addiction
involving alcohol or other drugs1 if they or
See Chapter VIII for a more complete discussion of
cost-related issues in addiction treatment.
' Those with health insurance, but with very high
medical expenses relative to their incomes.
* This survey did not address addiction involving
nicotine.
someone in their family needed it. This
perception was true across income levels: 67
percent of adults with annual incomes under
$50,000 said they would not be able to afford
treatment, as did 30 percent of those with
incomes between $75,000 and $100,000 and 25
percent of those with incomes above $100,000.
In addition to those with the lowest income
level, other groups most concerned about
affording addiction treatment include those with
a high school degree or less (65 percent), those
living outside of metropolitan areas (56 percent)
and adults ages 18-34 (56 percent). The survey
also found that 75 percent believe that people
with addiction may not get treatment because
they lack insurance coverage or cannot afford
it.134
Cost is a barrier to seeking treatment even for
people with adequate health insurance.135 Some
addiction treatment programs do not accept any
insurance payments— private or public— for their
services,136 and insurance coverage for addiction
treatment, when it exists, often has higher co-
pays and limited service coverage.137
With the current funding stream, you must be
very rich or very poor to get treatment. 138
—Johnny Allem
Founder and President
Aquila Recovery, Chartered
Former President and CEO
Johnson Institute
People with private insurance tend to have
greater concerns about cost and are likelier to
cite cost as a barrier to treating addiction than
people with Medicaid or Medicare. Those with
public insurance focus more on accessibility
issues (waiting times, eligibility) as barriers to
treatment.139 This disparity may be due to the
fact that some private insurance companies do
not cover addiction treatment and some
employers do not extend their benefit plans to
include addiction treatment coverage.140
Twenty-eight percent of respondents to the
NABAS think that one of the main reasons why
people do not get the help they need for
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addiction is because of insufficient available and
affordable treatment services.141 Treatment
providers see this as a barrier to treatment access
as well: CASA Columbia's survey of treatment
providers in New York State found that
approximately 90 percent of the respondents
said that inability to pay "somewhat" (44.6
percent of program directors and 42.8 percent of
staff providers) or "very much" (45.8 percent of
program directors and 50.7 percent of staff
providers) stands in the way of people receiving
needed addiction treatment.142
Cost not only is a barrier to entering treatment,
but to staying in treatment as well. One study
found that people randomly assigned to receive
free methadone maintenance therapy stayed in
their treatment programs longer than those
randomly assigned to fee-for-service treatment,
even though the fee was only $2.50 per day.143
Lack of Information about How to Get
Help
A significant barrier to obtaining addiction
treatment is the lack of knowledge about where
to go for help and the limited ability of
physicians, parents and other family members,
teachers, coaches, employers, clergy and law
enforcement to identify the signs of addiction in
others and know how to help patients access
effective treatment.144 The NABAS found that 16
percent of respondents believe that a main
reason why people with addiction do not get the
help they need is because of insufficient
information about how and where to get help.145
Limited Availability of Services
A significant barrier to treatment is the lack of
appropriate and accessible treatment services.146
This barrier is due to insufficient training of
medical professionals and treatment options and
the lack of treatment options tailored to
individual needs; excessively restrictive
eligibility criteria in some treatment facilities;
long waiting times for treatment entry and a lack
of trained addiction physician specialists and a
lack of inclusion of addiction medicine as a
recognized field of practice by the American
Board of Medical Specialties, as discussed in
Chapters IX and X.
Approximately half of respondents to CASA
Columbia's NABAS reported that insufficient
treatment programs and services for people with
addiction is a somewhat or very serious problem
in their communities.147 Another national poll
found that nearly half (47 percent) of the
respondents said that treatment services are
lacking in their community; only one quarter
indicated that there are enough affordable,
accessible quality treatment centers and
services.* 148 CASA Columbia's survey of
treatment providers in New York State found
that a significant proportion of the respondents
said that a lack of conveniently located treatment
programs "somewhat" (62.2 percent of program
directors and 56.8 percent of staff providers) or
"very much" (17.1 percent of program directors
and 21.6 percent of staff providers) stands in the
way of people seeking needed addiction
treatment.149
Some individuals who need addiction treatment
face eligibility criteria for program entry that are
too stringent-including a patient's ability to pay
and a required agreement to comply with all
rules and treatment protocols regardless of
individual goals.150 In contrast, the main
criterion for treatment access in mainstream
medicine is the principle of medical necessity,
determined by a physician;151 patients seeking
medical treatment rarely have to meet a
threshold level of problem severity or agree to
comply in advance with particular rules, unless
those rules are designed to protect the patient's
health and safety (e.g., refusing to give a patient
a certain medication that is contraindicated for
medical reasons, requiring cessation of certain
medications or behaviors prior to a surgical
procedure).
Those reporting the greatest concern about the
limited treatment options in their communities
included respondents with incomes below $50,000
(52 percent), blacks (67 percent), those who knew
someone with addiction (58 percent) and those who
did not have health insurance (56 percent).
-152-
Patients who do meet eligibility criteria and are
ready to enter treatment often face a long wait
for services-according to some estimates, up to
70 days152-due to limited treatment
availability.153 This barrier can undermine an
individual's fragile resolve to enter treatment.154
Long waiting times may bias treatment entry in
favor of those most likely to succeed with
treatment,155 as a longer wait time to enter a
program is associated with pretreatment
attrition.156 One study found that the longer
patients have to wait between clinical
assessment and the first treatment session, the
less likely they are to complete subsequent
treatment sessions.157 CASA Columbia's survey
of treatment providers in New York State found
that a significant proportion of the respondents
said that long waiting lists "somewhat" (40.2
percent of program directors and 49.3 percent of
staff providers) or "very much" (22.0 percent of
program directors and 21.0 percent of staff
providers) stand in the way of people accessing
needed addiction treatment.158
Insufficient Social Support
A lack of social support can serve as a barrier to
treatment access. Individuals with addiction
may be discouraged openly by family or friends
from entering treatment or may have more subtle
fears that loved ones will think badly of them or
will be embarrassed or ashamed if they enter
treatment.159 Even among those who may
otherwise seek treatment, continued substance
use in an addicted individual's family or social
network can increase the risk of continued use,
reduce the likelihood of treatment entry and
derail treatment efforts.160
Conflicting Time Commitments
Competing responsibilities and time
commitments related to one's family and career
are common reasons for not seeking
treatment.161 One study found that the
opportunity cost of a person's time-including
both time spent traveling to non-residential
treatment programs and time spent in treatment
that otherwise would be spent on work or leisure
activities-is one of the main barriers to seeking
treatment.162
Negative Perceptions of the Treatment
Process
Among those with addiction who accept that
they need to treat their disease are those who
believe they can manage it themselves, without
professional assistance.163 Such a belief may
derive from a misperception of what symptoms
and what level of symptom severity constitute
the disease of addiction and require professional
assistance, or it may derive from the belief that
treatment simply is not effective and will not
help.164 Some of this concern may be warranted
given the nature of the services offered.
(See Chapter X.)
Twenty percent of respondents to the NABAS
think that a main reason why people with
substance-related problems do not get the help
they need is that they do not believe that
treatment would help. 165 Treatment providers
see this as a barrier to treatment access as well:
CASA Columbia's survey of treatment providers
in New York State found that a significant
proportion of the respondents said that the belief
that treatment does not work "somewhat" (63.9
percent of program directors and 59.0 percent of
staff providers) or "very much" (32.5 percent of
program directors and 31.7 percent of staff
providers) stands in the way of people looking
for needed addiction treatment.166
Some individuals with addiction have negative
perceptions or a fear of treatment providers and
programs that may keep them from seeking and
accessing treatment.167 These perceptions can
be based on an individual's prior negative
experience in treatment, anticipation that the
treatment process will be unpleasant,
assumptions about the limited efficacy of
treatment or a general fear of what might happen
in treatment.168
With regard to smoking cessation, there is a
prevalent belief among smokers that certain
interventions, particularly nicotine replacement
therapy (NRT), may not be safe.169 One study
found that 66.0 percent of current and former
smokers expressed concerns about the safety of
NRT; those expressing concern were less likely
-153-
to use NRT in a cessation attempt (30 percent
vs. 49 percent).170
Legal Barriers
Unlike other chronic health conditions, addiction
involving illicit drugs, by definition, marks a
person as having engaged in illegal activity.
Treatment providers see this as a barrier to
treatment access: CASA Columbia's survey of
treatment providers in New York State found
that a significant proportion of the respondents
said that fear of being sent to prison or jail
"somewhat" (41.0 percent of program directors
and 42.8 percent of staff providers) or "very
much" (42.2 percent of program directors and
37.0 percent of staff providers) stands in the way
of people looking for needed addiction
treatment.171
Barriers to Treatment Access and
Completion in Special Populations
The barriers to treatment outlined above apply to
most individuals with addiction; however,
certain populations face additional barriers that
exacerbate the difficulty of accessing needed
treatment.*
Individuals with Co-occurring Conditions
An estimated 20 percent of the U.S. population
has a disability that limits their functioning.1 172
The special populations discussed in this section do
not necessarily mirror those discussed in Chapter VI
since not all populations that require specialized
screening or treatment protocols have barriers to
treatment access that surpass or differ from those of
the general population (e.g., individuals involved in
the justice system). Likewise, not all special
populations that have additional or unique barriers to
treatment access necessarily require specialized
screening or treatment protocols (e.g., rural
populations).
* Including individuals with sensory disabilities
involving sight or hearing; physical disabilities that
limit basic physical activities such as walking, lifting,
carrying; mental disabilities that involve difficulty in
learning, remembering or concentrating; or
disabilities that impede self-care such as dressing,
bathing or getting around.
People with disabilities use addictive substances
at nearly twice the rate of the general
population.173 While individuals with co-
occurring addiction and mental health disorders
such as anxiety and depression access treatment
at higher rates than individuals in the general
population (although most treatment facilities do
not provide services tailored to this
population),174 those with other disabilities that
impede functioning access treatment services at
substantially lower rates than the general
population.175
Many health and social service professionals fail
to identify the presence of risky substance use or
addiction in people with disabilities, 176 despite
their high rate of substance use.177 Many
barriers stand in the way of treatment for people
with disabilities, such as erroneous attitudes or
beliefs of medical providers,1 lack of staff
training in how to work with disabled people
and treatment methods and materials that are not
tailored to the needs of people with
disabilities.178 People with disabilities who have
addiction also may be deterred by
accommodation barriers to treatment, such as
lack of personal or public transportation to a
treatment center179 and facilities that do not have
adequate accommodations, such as restrooms,
parking facilities, hallways and ramps that are
accessible to patients with mobility
1 80
impairments.
Treatment personnel often do not have the
proper training to meet the physical and other
health care needs of patients with disabilities,
such as knowledge of sign language or Braille.181
In 2009, 27.7 percent of facilities offered
services in sign language for the hearing
impaired.182
1 e.g., believing that people with disabilities deserve
pity so they should be allowed more latitude to
engage in substance use.
-154-
Pregnant and Parenting Women
Barriers to treatment access and completion can
be particularly acute for women who are
pregnant or post-partum, despite the fact that
pregnancy may provide substance-using women
with the motivation they need to reduce their
substance use or seek treatment.183 In 2010,
only 15.9 percent of facilities nationwide that
provided addiction treatment services offered
services specific to pregnant or post-partum
184
women.
Limited availability of child care for parenting
women in addiction treatment is a significant
barrier to treatment entry and retention.
National data indicate that only 6.5 percent of
outpatient addiction treatment facilities that
serve women offer child care, although facilities
that served women only were significantly
likelier than facilities serving both men and
women to offer child care services.185
Some pregnant smokers report reluctance to quit
smoking due to fear of weight gain,186 not
believing in the harmful effects of smoking to
themselves or their fetus due to prior
pregnancies with no observable harm and a
social environment where smoking is
prevalent.187
Some women also fear being branded as "bad
mothers" by treatment personnel.188 One study
found that more than one-third of pregnant
smokers reported being apprehensive about
attending smoking cessation counseling because
they believed the counselor would judge them
harshly.189
Pregnant and parenting women might shy away
from accessing treatment for addiction involving
alcohol or other drugs (excluding nicotine) for
fear that entering treatment may result in losing
custody of their children;190 they may be
apprehensive of the involvement of child
protective services if they were to be identified
as having addiction.191 CASA Columbia's
survey of treatment providers in New York State
found that a significant proportion of the
respondents said that fear of losing child custody
"somewhat" (25.3 percent of program directors
and 37.0 percent of staff providers) or "very
much" (73.5 percent of program directors and
58.7 percent of staff providers) stands in the way
of people looking for needed addiction
1 9?
treatment.
Substance use during pregnancy is considered a
form of child abuse under civil child-welfare
statutes in 1 5 states and is considered grounds
for civil commitment (i.e., forced admission into
a treatment program) in three states.193 Pregnant
substance users have been charged with such
crimes as fetal abuse, child abuse and neglect,
delivering drugs to a minor, corruption of a
minor, assault with a deadly weapon and
manslaughter.194 Some states have used prenatal
substance use as grounds to terminate parental
rights.195
Adolescents
Few diseases affecting adolescents are as
extensively under-treated as addiction, even
though addiction is a disease with firm roots in
adolescence.196 The significant treatment gap in
the adolescent population- which is particularly
acute among black and Hispanic youth197-is due
in large part to the failure to understand the
developmental nature of addiction and the
failure of health care professionals to look for
and prevent risky substance use or to identify
and address addiction in their adolescent patient
populations.198
The Society for Adolescent Health and Medicine
has called for greater access for adolescents and
young adults to health care through
nontraditional health care providers such as
school health centers, community health centers
and other public health agencies that rely
primarily on public funding, and expanded
insurance coverage.199 Unfortunately, systems
responsible for the welfare of young people-
schools, juvenile justice, child welfare— too
often miss opportunities to intervene with young
people in need of treatment and continue to
allow them to fall through the cracks undetected
and unaided.200
Treatment models with a strong evidence base in
adult populations are not necessarily applicable
-155-
to the treatment needs of adolescents with
addiction.201 Yet, effective evidence-based
treatment approaches for adolescents do exist.202
Despite this, in 2010, only 28.8 percent of
facilities nationwide that provided addiction
treatment services offered adolescent-specific
203
services.
Barriers to treatment for adolescents include
lack of support among parents and school
personnel and lack of interest on the part of
adolescents in participating in treatment.204
These barriers may result in difficulty recruiting
adolescents to participate in treatment.205 One
national survey found that adolescents frame
their reasons for not wanting to participate in
treatment as they "are not ready to stop
substance use," "didn't want others to find out"
and because they "could handle the problem
without treatment"— barriers that are similar to
those offered by the general population and are
at least in part reflections of the disease itself
and of the stigma attached to it.206 Other barriers
include insufficient research on the safety and
efficacy of evidence-based addiction treatments
for use in adolescent populations, particularly
pharmaceutical therapies.207
Older Adults
Older adults are less likely than younger people
to be identified as having addiction or to be
referred to treatment;208 those who do try to
access treatment often have difficulty finding
age-appropriate treatment services.209 In 2010,
only 6.9 percent of facilities nationwide that
provided addiction treatment services offered
services specific to older adults.210
Older smokers, for example, may be less aware
of the harmful consequences of tobacco use and
may focus more on the perceived benefits, such
as its use as an aid in coping with stress or
controlling weight.211 Some may feel that it is
"too late" to reverse the effects of smoking and
therefore may not be motivated to seek out
smoking cessation services; this belief is
reflected in the failure of many health care
providers to counsel older adult patients to stop
smoking and support them through a cessation
attempt.212 Some physicians may have concerns
about the safety of prescribing pharmaceutical
interventions for smoking cessation to older
patients.213
Adults who develop late onset addiction
involving alcohol are less likely than those with
early onset addiction to have a family history of
addiction (21 percent vs. 72 percent) and are
more likely to try to hide their illness; further,
the symptoms associated with addiction
involving alcohol— such as disorientation or
confusion-may be misinterpreted as cognitive
or physical deficits such as dementia, depression
or other medical problems common in the
elderly.214
CASA Columbia's 1998 report, Under the Rug:
Substance Abuse and the Mature Woman, found
that when physicians were asked for five
possible diagnoses of a hypothetical 68-year-old
female patient with an array of complaints
typical of risky use of alcohol or prescription
drugs, only one percent identified a substance
use problem as a likely diagnosis. Contrary to
the evidence, only 62 percent of physicians
reported believing that addiction treatment is
somewhat or very effective for older women.215
The Homeless
Mental illness and co-occurring addiction are
highly prevalent in the chronically homeless
population.216 Addiction, like other health
problems in the homeless population, too often
goes unaddressed until it is severe enough to
require costly urgent care and hospitalization,
resulting in a great deal of unnecessary human
suffering and a serious, yet avoidable burden on
health care systems.217
Seeking addiction treatment may be a low
priority for homeless individuals who must
contend with the competing needs of securing
food, clothing and shelter and who rarely have a
network of social support to help them access
and succeed in treatment.218 Given homeless
individuals' lack of resources, their ability to
find appropriate treatment programs and pay for
In a study of men ages 60 and older admitted to a
VA geriatric outpatient treatment program.
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services can be extremely limited.219 However,
even with greater motivation and better access to
treatment, the environment in which many
homeless people spend their time—with high
rates of ambient substance use, crime and
violence-may present additional barriers to
seeking and receiving treatment.220
Lack of collaboration between social service
providers, public health systems and addiction
treatment programs is another significant
obstacle to addressing addiction in the homeless
population, resulting in a missed opportunity to
22 1
increase access to treatment.
Homeless individuals, who frequently have co-
occurring addiction and mental health disorders,
often are rejected by community-based
residential programs since housing programs for
the mentally ill frequently exclude substance
users, and those for substance users often
exclude those with serious mental illnesses.222
One study found that 60 percent of homeless
people who admitted to having addiction
reported that they were not eligible for addiction
treatment or subsidized housing. Forty-two
percent of those who did receive treatment
reported that their treatment was ineffective
because of a lack of aftercare and housing
services.223
Another study found that receipt of public
insurance was the strongest predictor of access
to treatment among homeless people relative to
other predictors. Jail stays, emergency
department visits and non-residential medical
care visits were not associated with increased
access to treatment, suggesting that referral links
between these services and addiction treatment
are not adequate.224
Veterans and Active Duty Military
According to the U.S. Department of Defense's
Task Force on Mental Health, service members
may be concerned that their substance-related
problems might impede their career
advancement, which can lead them to avoid
seeking timely care.225 Soldiers may be
reluctant to seek treatment for addiction because
self-referrals can be reported to their superiors;
the military has an established policy of
reporting mental health and substance-related
problems to superiors.226 The use of illicit drugs
or the misuse of controlled prescription drugs
can be grounds for dishonorable discharge.227
Any referral for additional mental health care in
a military treatment facility must be documented
in an individual's personal record which can
deter people from seeking such treatment.228
Data from 2007 show that since military
operations began in Iraq, army commanders
have dismissed more than twice as many
soldiers for drug use than they did in the same
period before the war.229 Drug use is
categorized as a form of "misconduct," which
discontinues some or all military benefits.230
Another barrier to accessing treatment for
veterans is the long wait time for initial
appointments or between appointments.231
Veterans with co-occurring health problems also
face barriers to treatment, including the practice
of requiring individuals to be substance free
prior to entering treatment for other co-occurring
conditions that are common among military
personnel, such as post-traumatic stress disorder
(PTSD).232
More generally, there is a significant shortage of
medical and mental health professionals to
address the complex medical and psychological
treatment needs of individuals returning from
military combat, as well as those of their family
members.233
Rural Populations
Rural populations face a considerable gap in the
receipt of needed addiction treatment.234
Limited accessibility to treatment services as a
function of geographic location presents a
significant obstacle to treatment access for
people living in rural areas235 since general
medical and specialty treatment services
typically are located in urban centers.236 Only
8.9 percent of all addiction treatment facilities
are located in a rural county that is not adjacent
The use of illicit drugs or the misuse of controlled
prescription drugs.
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to an urban county. In 2010, 8.9 million rural
residents had no access to inter-city public
transportation,238 posing a significant barrier to
treatment access.
Rural residents tend to have lower incomes and
are less likely than non-rural residents to have
health insurance, which limits their ability to
afford and pay for treatment.239 And since rural
residents are more likely than urban residents to
be self-employed, they have fewer encounters
with employee assistance programs.240 For these
reasons, rural residents who engage in risky
substance use or have other health problems tend
to delay seeking preventive care, resulting in the
need for more costly care in the future.241
Native Americans
National data on racial/ethnic differences in the
addiction treatment gap are limited with regard
to Native Americans due to small sample sizes
for this population.242 However, existing data
suggest that Native Americans are the likeliest
of all racial/ethnic groups to smoke and to meet
clinical criteria for addiction involving alcohol
and other drugs.243 National data also suggest
that the group with the largest treatment gap is
Native Americans.244 One estimate indicates
that less than one-fifth of addiction treatment
programs nationally offer specialty services for
Native Americans.245
Chapter VIII
The Spending Gap
Despite the evidence that risky substance use
can be identified and reduced through screening
and early intervention, and that addiction can be
treated and managed effectively with
psychosocial and pharmaceutical interventions,
financial investments in addressing risky
substance use and addiction are aimed
disproportionately at coping with the costly
health and social consequences of the disease
rather than at prevention and treatment. This
spending gap impairs health and imposes
extraordinary and unnecessary costs to
taxpayers. The continued inadequacy of
insurance coverage for these services further
flies in the face of a fiscally-sound approach to
disease prevention, treatment and management.
The Rational Approach to Risky
Substance Use and Addiction
The goals of medicine are the prevention of
disease, the diagnosis and treatment of illness or
injury and the relief of pain and suffering.1 The
general standard for determining what health
care services should be provided to patients is
the "reasonable and necessary" 2 or the
"medically necessary" standard.3 The definition
of what is considered necessary generally is
made by health care payers based on the strength
of the clinical evidence supporting the
effectiveness of interventions in improving
health outcomes.4 In the Medicare and
Medicaid programs, medical necessity is defined
in various ways but generally as the prevention,
diagnosis or treatment of illness or injury that
endangers life, causes suffering or pain, causes
physical deformity or malfunction or results in
illness or infirmity.5 Some states also require
that Medicaid services not be more costly than
reasonable available alternatives.6
See Chapters IV and V.
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The American Medical Association (AMA)
supports the ideal that all patients have "a basic
right to available, adequate health care"
regardless of the ability to pay.7 This ideal is
based on several arguments which assert a moral
obligation to treat injuries or diseases that
impede normal functioning.* 8
Addiction is not unique as a health condition for
which a lack of understanding of the nature of
the disease and its causes has resulted in
assigning blame to the patient and to inadequate
or misguided interventions; other historical
examples include tuberculosis, cancer,
depression and HIV-AIDS.9 However, once a
body of evidence exists about the nature of an
illness and how to address it, that information is
incorporated into medical practice and
reimbursement policies based on the obligation
of the profession to treat disease. Addiction is a
glaring example of practice lagging behind the
science.10 The science is unambiguous-
addiction is a complex brain disease with
significant behavioral characteristics11 that
results in unhealthy compulsive behaviors,12
diminished cognitive control,13 clinically-
significant impairment or distress14 and that can
lead to long-term disability and death.15 Our
continued failure to prevent and treat the disease
is inconsistent with ethical standards and the
goals of medical practice.
The collective social protection argument posits that
certain essential services, including safety and health
care, are a "collective responsibility" of society and
should be provided to all. The principle of fair
equality of opportunity calls upon institutions to
provide individuals with basic services needed to
pursue the normal range of opportunities that are
essential to a good life— to cultivate one's talents,
develop skills and formulate one's own life goals.
Costs of Our Failure to Prevent and
Treat Addiction as a Medical
Condition
Risky substance use and addiction constitute the
leading cause of death and disability in the
United States.16 The result of not providing
effective prevention and treatment services for
addiction is that the cost of addiction accrues,
driving many other diseases, later manifesting as
more expensive care and spilling out to costly
social consequences. '
Looking just at government spending, CASA
Columbia calculated that in 2005, 1 risky
substance use- and addiction-related spending
accounted for 10.7 percent of federal, state and
local spending, and that for every dollar federal
and state governments spent, 95.6 cents went to
pay for the consequences of substance use; only
1.9 cents was spent on any type of prevention or
treatment.5 The taxpayer tab for government
spending on the consequences of risky substance
use and addiction alone totals $467.7 billion a
year, almost $1,500 a year for every person in
America.17
The Largest Share of Costs Falls to the
Health Care System
The largest share of spending on the
consequences of risky substance use and
addiction is in health care.18 Persons with
addictive diseases are among the highest-cost
health care users in America:19 they have higher
utilization rates, more frequent hospital
admissions, longer hospital stays and require
more expensive health care services.20 Nearly a
third (32.3 percent) of all hospital inpatient costs
is attributable to tobacco, alcohol and other drug
use and addiction.21
Even family members of individuals with
addiction have approximately 30 percent greater
f See Chapter III.
* Most recent data available.
§ In addition, 0.4 cents was spent on research, 1.4
cents on taxation or regulation and 0.7 cents on
interdiction.
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health care costs compared to families with
similar demographic characteristics who do not
have a member with an addiction diagnosis.22
The health care costs associated with addiction
also stem from the impact that addiction has on
the ability to treat other diseases. Addiction
affects the body in ways that complicate health
care, for example, by weakening the immune
system.23 These costs, however, rarely are
recognized. One study found that from 1 994 to
2002, admissions of patients with addiction
increased 46 percent but hospital costs increased
134 percent; because only one percent of these
patients had a primary diagnosis of addiction,
the rise in costs was attributed to treating the co-
occurring medical illness (i.e., the primary
diagnosis).24
In 2010, only $28.0 billion (1.0 percent) of total
health care costs was spent on addiction
treatment-related services involving alcohol or
drugs other than nicotine. Approximately $13.0
billion was spent on treatment-related services
involving alcohol and $15.0 billion on
treatment-related services involving controlled
prescription or illicit drugs.' 25 Total costs of
treatment for addiction involving nicotine are
unknown.
In 2010, the U.S. spent $43.8 billion to treat
diabetes26 which affects 25.8 million people,27
$86.6 billion to treat cancer28 which affects 19.4
million people29 and an estimated $107.0 billion
to treat heart conditions30 which affect 27.0
million people,31 but only $28.0 billion to treat
addiction1 32 which affects 40.3 million
people.5 33
'Including medical, mental health and direct
treatment costs.
^ Treatment-related services include: detoxification
(which is not considered treatment) and diagnostic
and treatment services provided in inpatient settings
(usually a hospital), outpatient/ambulatory settings
(such as in a hospital outpatient department or
emergency department and in physicians' and other
medical professionals' offices and clinics) and
residential settings (24-hour care).
* There are no national data that document spending
on treatment for addiction involving nicotine;
although the cost estimate of $28.0 billion applies to
Cost Savings of Addiction
Screening, Intervention and
Treatment
There are no national data available on total
health care spending for screening or
intervention services;** 34 therefore, data on cost
savings from these services and from addiction
treatment come from individual studies rather
than national data sets.
In an effort to increase resources directed to
screening, intervention and treatment, much
attention has been focused on highlighting the
cost effectiveness of these services.35 While cost
effectiveness certainly is an important
component of resource allocation and targeting,
this standard as applied to addiction is a stark
reminder of the stigma attached to the disease.36
The United States does not use cost
effectiveness as a measure to determine which
health care treatments should be covered; in fact,
the treatment of addiction involving alcohol and other
drugs excluding nicotine, the prevalence estimate of
those with addiction (40.3 million) includes those
with addiction involving nicotine.
§ Due to data limitations, the prevalence estimates for
cancer and heart conditions include individuals ages
18 and older who have ever been told by a doctor or
other health professional that they have the condition
(cancer/malignancy or a heart condition). The
prevalence estimate for diabetes includes all ages and
the estimate for addiction includes individuals ages
12 and older; for diabetes and addiction, the
prevalence estimates include both diagnosed and
undiagnosed cases. In each case, total costs of
treatment are included without regard to age. The
cost estimates for treating diabetes, cancer and heart
conditions were inflated to 2010 dollars using the
medical inflation factor (7.9 percent) found in the
Substance Abuse and Mental Health Services
Administration's (SAMHSA) National Expenditures
for Mental Health Services and Substance Abuse
Treatment, 1 986-2005 publication.
The 20 1 0 National Drug Control Strategy reports
on spending in one grant program through SAMHSA,
which spent $29.1 million in grants to eight states to
provide screening, brief intervention and referral to
treatment services in general medical settings, and to
1 1 grant recipients to include training in these
services in medical residency training programs.
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almost no other disease is held to this standard.
However, if cost-effectiveness were an essential
factor in determining which medical services to
fund, then screening, interventions and treatment
for addiction certainly would be considered a
good investment.
One study found that the annual benefits in
avoided health care spending (i.e., cost-saving)
per person achieved through substance-related
interventions in 200 1 dollars ranged from $634
for brief physician interventions for risky
drinkers to $3,951 for standard residential
addiction treatment; the average annual savings
per person was $1,939 across all interventions.38
The projected cost to insurers of offering
comprehensive addiction treatment benefits also
is modest. According to a 1 999 study, the cost
of providing managed,* comprehensive*
addiction treatment benefits with low co-
payments* and no annual limits was $5. 1 1 per
member in 1996- 1997. 39 Adding managed,
unlimited addiction treatment benefits to a plan
that previously did not offer addiction treatment
benefits would increase costs5 only by an
estimated 0.3 percent.** 40 In 2001, the
Congressional Budget Office estimated that
mandating parity for mental health and addiction
treatment benefits would increase group health
insurance premiums by 0.9 percent initially and
by 0.4 percent in total after accounting for the
market-driven responses of health plans,
employers and workers to the higher
premiums.' ' 41 Studies of the effect of mandated
parity in Federal Employee Health Benefit Plans
have concluded that total plan spending per
Benefits carved out and provided by a large
managed behavioral health care organization.
* Including outpatient, intensive outpatient, inpatient
and residential treatment.
* $10 or less.
§ Costs include payments to providers; administrative
fees and profits are not included.
Assuming annual Health Maintenance
Organization (HMO) insurance premiums of $1,500
per member.
' r Market-driven responses include: reductions in
employers offering and employees enrolling in
employer-sponsored insurance, changes in the types
of plan offerings and reductions in scope of benefits.
member did not increase significantly while out
of pocket expenses for those who received
treatment benefits declined.42
Because cost-effectiveness research to date has
for the most part focused on the cost savings of
providing a particular service within a particular
population, it is not yet possible to generate an
overall estimate of the potential cost savings of
screening all patients for all forms of risky
substance use and providing appropriate
interventions, or for assessing the need for
treatment and providing these services.
However, as the following examples reveal, the
opportunity for cost savings is substantial.
Screening and Early Intervention^
Cost-benefit studies of screening and brief
interventions for tobacco and alcohol use among
adults and pregnant women have demonstrated a
range of potential costs savings.43 Numerous
studies have demonstrated that medical costs for
patients with addiction increase significantly as
these patients age,44 implying that the greatest
cost savings can be achieved by early
intervention and treatment. §§ 45 In the health
care field, treatment costs of up to $50,000 for
each year of life saved are considered to be a
worthwhile investment in health (i.e., cost
effective); in specialty care, such as cancer,
treatment costs of up to $200,000 may be
considered cost effective.46
Smoking. Smoking cessation programs yield
positive health outcomes at the low cost of
$5,000 per healthy year gained*** 47 compared to
$56,200 per year for Aspirin and statin therapy
11 Research is presented related to screening and
interventions for smoking and risky alcohol use.
Comparable research related to other drug use is not
available.
§§ Cost-benefit studies calculate the total cost savings
that result from providing treatment (sometimes
called return on investment); whereas cost-
effectiveness studies determine the treatment costs of
extending a patient's life by one year, or per quality-
adjusted life year (QALY), a year of perfect health.
Cost effectiveness as measured by costs minus
savings for each year of healthy life attributable to
the intervention.
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to prevent coronary heart disease, $191,635
per year for diet/exercise to prevent diabetes in
high-risk adults' and $30,619 per year for
biennial mammograms to screen for cancer
among women ages 50 to 79.49
Screening pregnant women who smoke can be
especially cost effective, given that the smoking-
attributable medical care needed by infants
whose mothers smoked while pregnant is an
estimated $367 million per year.1 50 A one-
percent reduction in the prevalence of smoking
in the U.S. population, including among
pregnant women, would reduce the number of
low-birth weight births by 2,000,§ resulting in
$21 million in avoided direct medical costs.
Continuing at that rate for another six years,
more than 57,000 low-birth weight births could
be prevented, saving $572 million.51
The American Legacy Foundation projected that
a reduction in Medicaid costs of nearly one
billion dollars** could be achieved by preventing
the current cohort of 24-year-oldstf from
smoking. If prevention and cessation efforts
were successful in motivating all Medicaid
recipients who smoke to quit, states' Medicaid
expenditures would be, on average, 5.6 percent
lower, resulting in a total of $9.7 billion in
savings after five years.52
Risky Alcohol Use. Screening and brief
intervention for risky alcohol use rank among
the top most cost-effective prevention services
available,53 along with colorectal cancer
For 45-year old men with a 10-year risk for
coronary heart disease of 7.5 percent. The
calculation includes the cost of medication plus
medical care including care for adverse events (e.g.,
Aspirin-induced gastrointestinal bleeding and
resulting morbidity and mortality).
* Costs include individually-tailored diet and exercise
plans, visits to a nutritionist and physical training
sessions.
*In 1996 dollars.
§ Based on 1995 birth rates.
** Over the cohort's lifetime.
' r The researchers chose this age because nearly all
smokers begin smoking before age 24, whereas
younger smokers may still be experimenting with
tobacco.
screening, hypertension screening and influenza
immunization.54
Research findings suggest that early
interventions8 for risky alcohol use may result
in health care cost savings of up to $43,000 for
every $10,000 invested.55 A study of primary
care screening and brief physician intervention
for adult risky drinkers yielded a net benefit of
$947 per person.56
The use of screening and brief interventions in
hospitals has demonstrated promising returns on
investment.57 A study of screening and brief
interventions for risky alcohol use among adults
in trauma centers estimated that over a three-
year period, the cost savings associated with
screening were $89 per patient55 and the cost
savings associated with brief interventions
lasting 30 minutes were $330 per patient. In
total, the implementation of a hospital-based
alcohol screening and brief intervention program
for risky alcohol use was estimated to reduce
health care costs by $3.81 for every dollar
spent.58 Brief interventions" ' with adolescents
ages 1 8 and 1 9 who were admitted to a trauma
center for alcohol-related injuries also have been
found to be more cost-effective than standard
59
care.
The return on investment in preventing Fetal
Alcohol Syndrome (FAS) further underscores
the importance of screening and early
interventions. The added medical costs for a
child with FAS are estimated to be more than
$2,300 per year for the first 21 years of a child's
life. An alcohol intervention program costing
$50,000 that could successfully prevent at least
one case of FAS annually would pay for itself in
just six years.60
11 Consisting of two doctor visits and two nurse
follow-up calls.
§§ Cost per screening was $16.
Cost per intervention was $38. Savings were
calculated based on average hospitalization and
emergency department costs; hospital recidivism
rates for trauma patients with and without addiction
involving alcohol; and the efficacy rate of screening,
brief interventions and referrals to treatment at
reducing injury, recidivism and hospital readmission.
' u Using motivational interviewing.
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Addiction Treatment and Disease
Management
Persons with untreated addiction have higher
health care utilization rates and more frequent
hospital stays, generating billions of dollars
in largely avoidable health care charges.61
Addiction treatment, particularly evidence-based
treatment, not only reduces health care costs in
both the short and long term, it saves lives and
reduces other social consequences and costs as
well* 62 Some research suggests that treatment
"pays for itself," often on the day it is delivered
and the total cost savings from addiction
treatment continue to accrue over time.63
While the total economic benefits of treatment
are greater than the cost of treatment,64
administrators and policymakers too often
disregard benefits of treatment that accrue
beyond the narrow silo of each individual
government program. For example, health care
payers may refuse to acknowledge the
significant cost savings that may accrue outside
the health care system (increased productivity,
reduced crime, etc.). An example of this can be
seen in an analysis of data from the VA health
care system from 1998 to 2006 showing that
providing addiction treatment resulted in an
overall increase in health care costs, presumably
because expanding access to treatment brought
more sick patients into the health care system
and more of their co-occurring medical
conditions subsequently were identified and
treated. The one exception was opioid
maintenance therapy which paid for itself in
health care savings. This study did not account
for potential longer-term reductions in health
care costs or for potential cost savings in other
sectors because it was taking the perspective of
an insurance payer— via the VA health care
system65— and this perspective tends to look at
short-term costs rather than long-term savings.
Most studies— even those that look only within a
particular system for costs and benefits— find
immediate and longer-term savings associated
with addiction treatment:
The referenced studies do not include detailed
examples of the nature of the treatment provided.
• A longitudinal study of patients treated for
addiction in Kaiser Permanente's Medical
Care Program found an average reduction of
30 percent in medical costs three years post-
treatment. Significant declines were seen in
areas such as the number of inpatient
hospital days and emergency department
visits, which are high-cost services.66
• A comparison of adult patients who met
clinical criteria for addiction involving
alcohol or drugs other than nicotine who
were enrolled in an outpatient treatment
program with a control group ' found that
those enrolled in the treatment program were
less likely to be hospitalized 1 8 months after
treatment than before treatment. The study
also found that treatment can cut health care
costs associated with addiction by about one
quarter, primarily by reducing the number of
annual hospital stays and the likelihood of
emergency room visits.67
• An analysis of data from patients in
treatment for addiction involving alcohol or
drugs other than nicotine in California found
a benefit-cost ratio of more than seven to
one'} the average cost of treatment was
$1,583 and the benefits§ were $1 1,487.
Most of the savings were attributed to
reduced crime and increased employment.68
• An analysis of statewide data from
Washington State found that treatment was
associated with an annual $2,500 reduction
in medical expenses** among adult patients
' Adults who met criteria for addiction involving
alcohol or other drugs but did not receive treatment.
* Nine months after treatment.
§ Including earnings from employment and reductions
in the costs related to emergency department visits,
incarceration and crime.
** Including inpatient and outpatient hospital care,
physicians' services, prescription drugs and nursing
home care. Most of the reductions in medical
spending were within Medicaid expenditures.
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with addiction receiving general assistance
welfare.69 A more recent analysis in
Washington State of the return on
investment from an increase in addiction
treatment for disabled adults enrolled in
Medicaid or medical coverage through a
general assistance welfare program between
2006 and 2009 found a savings of $2.07 in
medical and skilled nursing facility expenses
for every dollar spent on treatment' over the
four-year period.70
• A performance audit of the costs and
savings to the Colorado Medicaid Program—
which in 2006, implemented a benefit to
provide outpatient addiction treatment for
services related to tobacco, alcohol and
other drugs for all Medicaid beneficiaries-
found that the program cost $2.4 million
over the course of three years while medical
costs for patients receiving services under
this program declined by approximately $3.5
million/ 71
• A simulation of potential cost savings in the
justice system demonstrated that treating all
arrestees who are at risk of addiction would
cost $13.7 billion and save more than $46
billion (for every dollar spent on treatment,
more than three dollars in benefits accrue).
Treating all arrestees who are "probably
guilty"5 and who are at risk of addiction
would result in a reduction in recidivism
rates in the range of 16 to 34 percent,
depending on the modality of treatment
(with long-term residential treatment
yielding the greatest reduction in recidivism,
roughly 27 to 34 percent).72
Measured as receiving a clinical diagnosis of
alcohol or other drug dependence or psychosis,
receiving detoxification services or having been
referred for alcohol or other drug assessment by the
state division of alcohol and substance abuse.
* In this study, treatment included outpatient,
residential and opioid maintenance therapy and case
management.
* Analysis based on available Medicaid claims data,
not a controlled longitudinal study.
§ As phrased by the authors of the study who state
that an admission of guilt generally is required for
enrollment in court-monitored treatment.
Addiction Involving Nicotine. One study
found that 24.6 percent of adult depressed
smokers who received six sessions of mental
health counseling and up to 10 weeks of nicotine
replacement therapy (NRT) with the patch were
abstinent from smoking after 18 months; the
total cost of treatment (smoking cessation
services plus mental health care) was $9,580 per
life year** gained.73
Following the implementation of Medicaid-
covered pharmaceutical therapy for addiction
involving nicotine, Massachusetts had a 46
percent annual decrease in hospitalizations for
heart attacks and a 49 percent annual decrease in
cases of coronary atherosclerosis. ft 74
Addiction Involving Alcohol. For individuals
with addiction involving alcohol, a number of
pharmaceutical interventions have been found to
be cost effective, including medical management
with naltrexone therapy and combined
naltrexone and acamprosate therapy.75
Even among patients who already have
developed an alcohol-related illness (such as
alcohol-related liver damage or psychosis),
treatment may reduce future health care costs.
Naltrexone therapy is related to less of an
increase in health care expenditures for
individuals with alcohol-related illnesses
compared to a control group1* ($63 increase
among naltrexone recipients vs. $814 increase
among controls). Those in the control group
were more likely to have an alcohol-related visit
to the emergency department during the study
compared to patients taking naltrexone (15
percent vs. nine percent).76
Addiction Involving Other Drugs. One study
examined the cost effectiveness of providing
The cost of extending a patient's life by one year is
a common metric used in cost-effectiveness studies.
' 1 There were, however, no significant changes in
rates of hospital admissions for respiratory conditions
including pneumonia, asthma, chronic obstructive
pulmonary disease and respiratory failure.
Individuals with the same range of alcohol-related
illnesses who were not prescribed naltrexone.
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treatment to pregnant illicit drug users and
calculated an average net savings of $4,644 per
mother/infant pair.77
An examination of health care and pharmacy
costs for patients with addiction involving
opioids in a large U.S. health plan revealed that
total health care costs (including inpatient,
outpatient and pharmacy costs) six-months post-
treatment were 29 percent lower for patients
who received medication than for patients who
received medication- free treatment ($10,192 vs.
$14,353).78
A study of the cost effectiveness of short-term
opioid replacement therapy' compared to
detoxification only calculated a cost-
effectiveness ratio of $1,376 in opioid
replacement therapy costs per quality-adjusted
life year (QALY).79 Another study projected
that methadone maintenance therapy costs
$5,915 for every year of life gained.* 80 In HIV
populations, expanding methadone maintenance
capacity for heroin users is cost effective, at
$8,200 per QALY gained in communities with
40 percent HIV prevalence among injection drug
users and $10,900 per QALY gained in
communities with five percent HIV prevalence
among injection drug users.81
Insurance Coverage of Addiction
Treatment is Limited
Recently-enacted federal and state parity laws
have expanded coverage for addiction treatment
where offered, and the Patient Protection and
Affordable Care Act (ACA) holds potential for
further expansion of access and benefits.
However, insurance coverage of addiction
treatment remains severely limited in both the
populations and services that are covered. The
absence of mandated coverage in all health plans
means that some health plans may continue to
choose not to provide coverage for addiction
treatment, persisting to deny access to patients
who need it.83
Parity Laws
Federal and state parity laws require private
insurers that provide mental health and addiction
treatment services to provide them on par with
medical services. In general, restrictions placed
on addiction services (e.g., co-pays, deductibles)
cannot be more restrictive than restrictions
placed on other medical services.84
Specifically, while the Mental Health Parity Act
(MHPA), passed in 1996, did not apply to
addiction treatment,85 the 2008 Paul Wellstone
and Pete Domenici Mental Health Parity and
Addiction Equity Act (MHPAEA) was enacted,
in part, to address this omission.86 The
MHPAEA provisions apply to:
• Plans sponsored by private and public sector
employers with more than 50 employees and
that include medical/surgical and mental
health/addiction benefits;5
The use of evidence-based approaches in
treatment will be driven by policy. We need to use
the payment system to drive changes in practice?2
-Jeffrey Samet, MD
Professor of Medicine and Social Behavior,
Clinical Addiction Research and Education
(CARE) Program
Boston University School of Medicine
One week of residential care followed by intensive
outpatient (day treatment) services through labor/
delivery.
' Patients, ages 15-21, received 12 weeks of
buprenorphine -naloxone therapy and also were
offered twice-weekly counseling. § Applies to plan years beginning on or after July 1,
* Assuming annual treatment costs of $5,250. 2010.
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• Medicaid managed care plans and
benchmark/benchmark-equivalent plans '
that provide mental health/addiction
benefits; and
• State plans within the Children's Health
Insurance Program (CHIP).88
Under the law, plans that offer addiction
treatment benefits cannot impose limitations on
these benefits that are more restrictive than
limitations placed on medical and surgical
benefits.1 89
In addition to the federal parity laws, 49 states
and the District of Columbia have some type of
parity law for mental health services; at least 38
states include coverage addiction involving
alcohol and/or other drugs. While the scope of
these laws varies, some are stronger than
MHPAEA.§ 90
This includes traditional and benchmark/benchmark
equivalent managed care plans. In Medicaid
benchmark/equivalent plans' benefits are determined
by comparison to BlueCross/BlueShield, state
employee benefit plans, certain Health Maintenance
Organization (HMO) plans or benefits that include
the basic services defined in Section 1937(b)(2) of
the Social Security Act.
1 The ACA extends certain MHPAEA parity
requirements to Medicaid benchmark and benchmark
equivalent plans that are not managed care plans that
provide mental health or addiction treatment benefits.
* The interim final regulations, which went into effect
on April 5, 2010, address how health plans must
comply with MHPAEA and how health plans may
define covered services that are consistent with
current medical standards. The regulations define
classification of benefits (such as inpatient, in-
network or prescription drug benefits); financial
requirements (such as deductibles and out-of-pocket
maximums); treatment limitations defined both
quantitatively (limits on day visits or frequency of
treatment limits) and qualitatively (standards for
provider admission into a network or prescription
drug formulary design); and how to determine
whether these restrictions comply with the law.
§ State parity laws generally fall into three categories:
(1) mental health parity/equal coverage laws in which
insurers must provide the same level of benefits for
addiction treatment as they do for other health
conditions; (2) minimum mandated mental health
benefit laws in which some coverage must be offered
A recent government evaluation found that post-
MHPAEA, 96 percent of employers' plans
continued to offer both mental health and
addiction treatment services, two percent
continued to cover only mental health services
and another two percent discontinued their
coverage of addiction treatment services. Plans
also indicated that they had reduced service
limitations on addiction-related services after
MHPAEA. In general, patients' average cost-
sharing burden declined after the MHPAEA,
with the exception of co-payments for office
visits which increased slightly.91 (Table 8.1)
Table 8.1
Employers' Insurance Coverage of Addiction
Benefits Since Enactment of the MHPAEA
2008 Plan
Year
2010/2011
Plan Year
Employers including
addiction benefits in
most popular plan
97%
97%
Employers placing
limits on office visits
for addiction care
33%
8%
Employers placing
limits on inpatient
days for addiction care
27%
8%
Average office visit
copayment
$25
$27
Average office visit
coinsurance
22%
19%
Average outpatient
services copayment
$39
$33
Average outpatient
services coinsurance
26%
19%
Source: United States Government Accountability
Office. (2011).
Analysis of national data found that in states
with broad parity laws (where benefits for the
treatment of addiction and mental illness are
mandated in at least some health plans and must
be offered at parity with medical and surgical
benefits), there was a 12.8 percent increase
but disparities in level of benefits provided are
permitted; and (3) "mandated offering laws" in which
an option of coverage for addiction treatment is
offered and, if coverage is accepted, benefits must be
equal with other health benefits.
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between 1 992 and 2007 in total treatment
admissions compared to states with weak parity
laws (in which parity laws were absent or did
not include addiction treatment services). In
comparison, in states with limited parity laws (in
which parity was mandated but with limitations
such as applying to certain groups or a limited
number of health plans), there was only a 4.7
percent increase (compared to states with weak
parity laws) in addiction treatment admissions
during this time.92
Among adolescents who received both an
addiction and psychiatric diagnosis, those living
in a state with a parity law expanding coverage
for addiction treatment are 4.5 times as likely to
be diagnosed with addiction and 3.2 times as
likely to receive treatment as adolescents in
states without such parity laws.93
The Patient Protection and Affordable
Care Act of 2010
The Patient Protection and Affordable Care Act
(ACA) of 20 1 0 was enacted to expand access to
insurance for the uninsured, to make health care
more affordable and to reform health care
delivery systems to improve quality.94 The
federal government estimates that the ACA
could expand coverage for addiction treatment
to an additional 4.8 million Americans if
coverage is offered at parity with other health
benefits.* 95
plans as part of an "essential health benefit"
package.97 The ACA also extends requirements
of MHPAEA to some health plans to which the
law did not previously apply/ 98
One main goal of the ACA is to increase the
number of people who have health insurance by
making more people eligible for Medicaid,99
allowing individuals who do not have insurance
through their job to obtain insurance in state
exchanges (transparent and competitive
marketplaces), offering them income-based tax
credits and subsidies100 and allowing young
adults under age 26 to remain covered by their
parents' insurance plan.5 101
The ACA also attempts to change the way health
care is delivered to improve quality and integrate
addiction treatment into medical care, for
example through demonstration projects like
Medicaid health homes, where teams of health
professionals care for individuals with chronic
conditions including addiction;102 accountable
care organizations (ACOs), in which groups of
health professionals coordinate services for
Medicare fee-for-service patients;103 and through
temporary funding to expand the role of
community health centers.104 If these initiatives
are successful and become common practice,
they will help to integrate the treatment of
addiction into mainstream medical practice and
expand the use of pharmaceutical therapies.105
The ACA has the potential for increasing access
to addiction- related services by (1) increasing
the number of people who are covered by health
insurance96 and (2) requiring that addiction
treatment benefits be offered by certain' health
This estimate was for those who buy coverage in the
individual market, and while these plans must
provide some form of addiction treatment as part of
Essential Health Benefits, states have not yet defined
their Essential Health Benefits. It is unclear how
many states will include the full range of necessary
services for addiction treatment in their definition.
f Including new small fully-insured or self-insured
plans, new individual market health plans, qualified
health plans (as defined by the ACA), Basic Health
Programs and Medicaid benchmark/equivalent plans.
* The ACA requires that qualified health plans
offered through the exchanges, individual (non-
group) market plans and Medicaid non-managed care
benchmark and benchmark-equivalent plans comply
with MHPAEA.
§ Even if they are married, in school or eligible to
enroll in their employer's plan. Plans that existed on
March 23, 2010 do not have to offer dependent
coverage until 2014 if the dependent is eligible for
employer-sponsored insurance.
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Gaps in Coverage within Public and
Private Insurance Plans Continue to
Impede Comprehensive Addiction Care
Screening and Interventions for Risky
Substance Use. Recent developments in
Medicare and Medicaid reimbursement have
begun to remove some of the cost barriers that
health professionals faced in routinely screening
their patients for risky use of addictive
substances and conducting early interventions
when necessary.106
For example, the U.S. Department of Health and
Human Services' Centers for Medicare and
Medicaid Services (CMS) adopted Medicaid
billing codes for screening and brief intervention
services; in January 2007, these codes became
effective.107 The Medicaid codes cover these
services related to alcohol and other drugs
(excluding nicotine).108 These codes are
available for health care providers in individual
states to use but there is no requirement for
providers to use the codes. Individual states
determine which services are reimbursed and, to
be operational, states have to enable the billing
codes; however, many have not done so.* 109
With regard to smoking, the only screening
services that states explicitly are required to
provide are those that fall under the Early and
Periodic Screening, Detection and Treatment
(EPSDT) Program— the child health component
of Medicaid which is required for each state to
finance appropriate and necessary pediatric
services, including tobacco cessation services
for youth; as of2000,T 15 states explicitly
require providers to screen youth for tobacco
use.110 (See next section on treatment for
information about coverage for smoking
cessation services.)
In 2008, CMS adopted Medicare billing codes
for structured assessments1 and brief
intervention services related to the risky use of
alcohol and other drugs (excluding nicotine) for
And these codes do not cover screening and
intervention services for all addictive substances.
' Most recent available data.
* Structured assessments involve the use of validated
tools such as AUDIT or DAST (see Appendix H).
patients who show signs/symptoms of
substance-related problems.111 These services
were reimbursed only when reasonable and
necessary to diagnose or treat illness or injury.112
In October 201 1, CMS determined that
Medicare would provide coverage in primary
care settings8 for preventive annual alcohol
screening of all patients and up to four brief,
face-to-face interventions for Medicare
beneficiaries who screen positive for risky
alcohol use but who do not meet clinical criteria
for addiction involving alcohol.113 Medicare
does not reimburse for population-wide
screening and brief interventions to address the
risky use of illicit and prescription drugs because
it is not yet recommended by the U.S.
Preventive Services Task Force (see Chapter
iV).tt 114 Although there are no specific
Medicare codes for general tobacco use
screening, questions about tobacco use are
considered part of the medical history to be
collected, for example, during the Initial
Preventive Physical Examination for those new
to Medicare.115 As of August 2010, Medicare
does cover preventive tobacco cessation
counseling for smokers who do not present with
signs or symptoms of tobacco-related disease.
The benefit includes two individual tobacco
cessation counseling attempts per year, with
each attempt consisting of up to four sessions.116
Despite the facts that the American Medical
Association (AMA) has published Current
Procedural Terminology (CPT) codes for
screening for tobacco use** 117 and risky use of
alcohol and other drugs118 and that most private
insurance plans cover these services,119 patients
are not routinely screened for risky use or
provided brief interventions if indicated. A
2009 survey found that very few claims have
been paid by commercial insurance plans for
s Including outpatient hospital settings.
** But not for other substances. Medicare allows
providers to choose any screening tool that is
appropriate for their clinical population and setting.
' 1 Medicare does cover structured assessments to
evaluate and provide interventions for patients who
exhibit symptoms of addiction involving drugs.
CPT codes for tobacco screening include the codes
for "health and behavior assessment" and other
preventive medicine services.
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alcohol and other drug screening and brief
intervention services.120 Although 76 percent of
smokers in commercial health plans reported
being advised by their physician to stop smoking
in a 2008 survey; only half recalled being
advised about smoking cessation strategies or
medications.121
The ACA was designed to increase the number
of individuals covered under Medicaid and
commercial insurance,* 122 but also allows states
facing budget deficits to scale back eligibility
under certain circumstances. f 123 Because of
economic constraints, states appear to be cutting
back on health services rather than assuring
access to these services.1 124
An additional resource problem that stands in
the way of screening and early interventions is a
legal statute dating back to 1947, the Uniform
Accident and Sickness Policy Provision Law
(UPPL)}15 Under the UPPL, insurers can deny
payment for treatment of injuries sustained by a
person under the influence of alcohol or other
drugs.§ 126 In states that adopted UPPL, EDs and
trauma centers might not screen for risky
substance use because reimbursement for the
emergency or trauma services they provide
could be denied; as a result, critical
opportunities for intervention are missed. 127
Because of the barriers the UPPL imposes to
The ACA mandates no co-pay in private insurance
and self-insured plans for alcohol screening and
counseling; alcohol and other drug use assessments
for adolescents; tobacco use screening for all adults;
and cessation interventions for tobacco users.
' States are permitted to scale back eligibility if they
have expanded their Medicaid programs to non-
pregnant, non-disabled adults with incomes over 133
percent of the poverty level.
* At least 3 1 states have implemented cuts that will
restrict eligibility for health insurance programs
and/or access to health care services.
§ The law originally was adopted to control insurance
costs at a time when little knowledge was available
about addiction and when access to treatment was
limited. The statute states: "The insurer shall not be
liable for any loss sustained or contracted in
consequence of the insured's being intoxicated or
under the influence of any narcotic unless
administered on the advice of a physician."
needed screening and interventions for risky
substance use, the AMA has been working to
overturn the law and prohibit other state laws
modeled on it.** 128 As of January 201 1, 25
states still have the UPPL or a history of court
decisions that permit insurers to use an alcohol
exclusion to deny payment for treatment; 1 6
states and the District of Columbia prohibit
denial of benefits." 129 A similar legal provision
allows many states to deny disability payments
or workers' compensation to individuals harmed
while under the influence of alcohol or while
participating in an illegal act, such as driving
under the influence.130
Treatment for Addiction. Current coverage of
addiction treatment is not designed to prevent
and treat the disease effectively. There is
considerable variability in coverage within and
among public and private insurance plans which
poses significant barriers to treatment
accessibility.
Medicaid. The Medicaid program is the major
public health coverage program for low-income
Americans.131 With the exception of the ACA's
"essential health benefits" requirement/*
addiction treatment services are not federally
mandated in Medicaid,132 nor are any addiction
treatment services that are eligible for
reimbursement defined at the federal level.133
However, states may provide addiction-related
services under several of the mandatory benefit
categories:
• Physician services; 134
• Inpatient services provided in a general
hospital, such as inpatient detoxification,135
but not including room and board charges in
In 2001, the National Association of Insurance
Commissioners, which originally adopted the UPPL
as a model law in 1947 and encouraged states to
implement it, reversed their position and
recommended the repeal of the UPPL. Since that
time, several organizations along with the AMA have
pledged support for repealing the UPPL.
' r Other states do not explicitly permit or prohibit
alcohol exclusion provisions.
M Applies to Medicaid benchmark/equivalent plans.
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residential specialty treatment settings or
inpatient care for patients ages 22- to 64-
years old in institutions for mental
disease;136 and
• Outpatient hospital care,* including
detoxification, individual, group or family
counseling and/or psychotherapy, and
diagnosis, treatment, assessment and
medication management.137
Optional benefit categories under which
addiction-related treatment services also may be
provided include:
• Outpatient rehabilitation services, including
diagnostic and treatment services. States
providing optional benefits under Medicaid
often choose this option since it does not
require services to be provided under the
direction of a physician and instead permits
the delivery of services including mutual
support by community paraprofessionals and
• Clinic services; and
• Case management services.140
Last, states may provide addiction treatment
services as part of a Medicaid managed care
waiver program.1 141
Because state Medicaid plans vary widely in
their eligibility requirements and benefits,
individuals have substantially different access to
care depending on the state in which they live.
Some states cover a broad range of addiction-
related services; others provide only a few and
i • 142
two states cover no such services.
State Medicaid programs also distinguish
between services offered for addiction treatment
Several states specifically exclude addiction
treatment from the outpatient services benefits and
some place limits on the services such as number of
visits per year.
' A 2006 survey found that 3 1 states offer addiction
treatment through a managed care waiver program.
involving nicotine and treatment involving
alcohol and other drugs.
With regard to smoking, Medicaid plans are
required to provide tobacco cessation counseling
and pharmaceutical treatments to pregnant
women, children and adolescents. States are
free to choose whether or not to include tobacco
cessation benefits for other enrollees.143 In
2009, 1 8 states covered individual counseling
for all Medicaid enrollees, seven states covered
counseling only for enrollees in some programs
(fee-for-service or managed care) and six states
covered it only for pregnant women. Eight
states covered group counseling for all Medicaid
enrollees, five covered group counseling only
for enrollees in some programs (fee for service
or managed care) and five states covered group
counseling for pregnant women only. As of
2009, 34 states covered the nicotine patch for all
Medicaid enrollees, 33 covered bupropion, 32
covered nicotine gum, 32 covered varenicline,
28 covered nicotine nasal spray, 27 covered
nicotine inhalers and 25 covered nicotine
lozenges.144 As of 201 1, six state Medicaid
programs provide comprehensive coverage for
smoking cessation treatments for all Medicaid
enrollees, while five state Medicaid programs
provide no coverage for cessation treatment for
any enrollees.145
Medicare. Medicare is a federally-funded
system for financing health care for U.S. citizens
ages 65 and older and people under age 65 with
certain disabilities.146 Medicare covers the
following services, when medically necessary:
• Inpatient hospital services for detoxification
for addiction involving alcohol and
outpatient services for detoxification for
addiction involving drugs other than
147
nicotine;
• Inpatient rehabilitation treatment for
addiction involving alcohol, controlled
prescription drugs and illicit drugs in an
acute care or psychiatric hospital;148
• Outpatient hospital-based diagnostic and
therapeutic services for treatment of
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addiction involving alcohol, and outpatient
hospital services involving detoxification,
rehabilitation and treatment for addiction
involving drugs other than nicotine;149
• Clinic-based treatment services for addiction
involving alcohol and detoxification services
for addiction involving opioids, under
physician supervision;150 and
• Tobacco cessation counseling from a
qualified physician or practitioner for all
smokers and tobacco cessation medications
prescribed by a physician.151
Methadone maintenance therapy also is covered
on an outpatient basis, but only when indicated
for pain, and in hospitals for treatment of
addiction involving opioids.152
Differences in copayments for outpatient
addiction treatment and other outpatient services
will be phased out by 20 14. 153
Private Health Insurers. Historically, private
health insurers have provided less coverage for
the treatment of addiction than for other health
conditions by setting lower annual or lifetime
limits on benefits,' covering fewer inpatient days
or outpatient visits and increasing cost sharing
through higher deductibles and copayments.154
A survey of private health plans found that,
while only 1 6 percent of private insurance
offerings imposed lifetime limits on addiction
treatment, 94 percent had annual limits for
outpatient services and 89 percent had annual
limits for inpatient services. Private insurance
offerings were more likely to limit visits
(outpatient) or days (inpatient) than to limit
spending.155
Medicare covers two individual cessation
counseling attempts per year, and each attempt may
include up to four sessions.
' Annual limits are caps that insurers place on the
benefits an enrollee is entitled to each year. Limits
can apply to particular services (e.g.,
hospitalizations), number of visits or dollar amount
of covered services. Lifetime limits are caps on
expenditures, on specific services or both during an
individual's lifetime.
Children's Health Insurance Program ( CHIP).
Under CHIP, formerly the State Children's
Health Insurance Program (SCHIP), states are
entitled to federal matching funds up to specified
limits to finance health care for low-income
children1 who do not qualify for Medicaid.156
States can provide benefits related to substance
use and addiction under CHIP by expanding
children's eligibility under Medicaid, by
creating a separate insurance program or through
some combination of these approaches. States
that opt simply to expand their Medicaid
programs are required to follow the rules and
requirements of Medicaid.157 States that provide
benefits by creating unique CHIP programs
(outside of Medicaid) must provide a benefits
package equivalent to one of several
"benchmark" insurance plans. § 158 States have
latitude in designing their CHIP program.159 A
2000 study found that almost all states provided
at least one of detoxification, inpatient/
residential or outpatient services, though many
states imposed annual limits (e.g., 20 or 60 visits
per year) or lifetime benefit limits (e.g., $16,000
or $20,000). 160
Gaps in Addiction Care Coverage Within
Parity and Health Reform Initiatives. With
regard to federal parity laws, MHPAEA includes
an exemption if the financial burden of
implementing the law is too great,** 161 and small
employers (with less than 50 employees) are
exempt from the law completely.162 Under
MHPAEA, insurance plans may cap services
1 Through waivers, states may expand CHIP
eligibility to pregnant women, low-income parents
and adults without children.
§ Such as the Blue Cross/Blue Shield Standard
Option Service Benefit Plan offered under the
Federal Employees Health Benefits Program
(FEHBP), a plan that is available to the state's
employees or a plan offered by the HMO with the
largest enrollment in the state outside of Medicaid.
States also may use a benefits package that is
actuarially equivalent to one of the benchmark plans,
an already existing state-funded plan or any other
plan approved by the federal government.
Health plans are exempt if complying with the law
results in a cost increase of greater than two percent
in the first plan year and greater than one percent in
subsequent years.
-172-
(e.g., number of visits per year) as long as the
caps are equivalent to those placed on medical
services.163 Placing blanket limitations on
allowed visits or length of stay, however, does
not accord with best practices for treating cases
of addiction that are chronic and relapsing.164
Challenges to implementing MHPAEA in
practice include a lack of education among
medical professionals in how to screen,
intervene and treat addiction and a lack of
addiction physician specialists.165
With regard to state parity laws, self-insured
employer-sponsored health plans are exempt
from state regulation under the federal
Employee Retirement Income Security Act
(ERISA) of 1974. 166 Furthermore, coverage for
mental health and addiction services varies
dramatically by state, depending on the strength
of the state's parity law.
With regard to the ACA, despite the
improvements in treatment coverage that will
arise from its passage, many limitations remain
both in policy and practice. Its impact on
treatment access remains to be seen since many
of the provisions of the law have not yet taken
effect. For example, the expansion of Medicaid
as a payer likely will result in reductions in
federal and state grants for residential care
(which is not covered by Medicaid). As a result,
care may transition toward outpatient
treatment167 which may be inadequate in some
cases, such as for treating patients with more
severe addiction.
Expanding access to insurance is necessary but
alone is not sufficient to expand access to care.
In 2006, Massachusetts enacted health care
reform legislation similar to the ACA which,
among other things, established universal health
insurance through individual mandates to
purchase insurance and government subsidies.168
In the years following, addiction treatment
admission rates did not increase significantly.
Despite the fact that the total uninsured
population dropped to three percent, a large
number (23-30 percent) of patients with
addiction remained uninsured, either due to non-
compliance with the mandate to obtain
insurance, inability to pay even with subsidies or
logistical barriers such as lack of documentation
or a stable home address. For some of those
who were successful in becoming insured, co-
insurance and co-payments rendered treatment
unaffordable.169 Furthermore, expanding
insurance coverage does not automatically
translate into expanded screening and diagnosis
by health professionals or capacity to treat large
numbers of newly-insured patients.
Similarly, requiring parity for addiction benefits
in Federal Employee Health Benefit (FEHB)
plans did not result in increased treatment rates.
An analysis of nine large FEHB plans in the two
years before and after the parity requirement
found that the number of new diagnoses of
addiction increased; however, utilization rates
for addiction treatment benefits were
unaffected.170
The ACA includes 1 0 categories of essential
health benefits (EHB)— including addiction
treatment-that must be provided by newly-
created individual and small group plans.171 Yet
rather than defining what these services must
include, the federal government has proposed
that each state design its own EHB package,* 172
meaning that benefits will vary across states.
Furthermore, the EHB provisions do not apply
to self-insured group health plans, large group
market health plans or already existing small and
individual market ("grandfathered") health
plans.173 The provisions that would expand
coverage and require EHBs do not go into effect
until 2014.174
Efforts to control spending and legal challenges
may limit some intended effects of the ACA.
States may respond to fiscal challenges by
attempting to control costs in their Medicaid
programs by cutting services.175 Moreover, the
ACA faces challenges in the U.S. Supreme
* Within limits-the plan must be comparable to a
benchmark plan: (1) the largest plan by enrollment in
any of the three largest small group insurance
products in the state's small group market; (2) any of
the largest three state employee health benefit plans
by enrollment; (3) any of the largest three national
FEHBP plan options by enrollment; or (4) the largest
insured commercial non-Medicaid HMO operating in
the state.
-173-
Court over two provisions that would expand
coverage: the Medicaid expansion and the
requirement for individuals not covered under
public programs or by employer-sponsored
insurance to purchase insurance; the Court's
decision would have implications not just for
these provisions but for other parts of the law as
For example, if the Supreme Court decides that the
individual mandate is unconstitutional and not
severable from the rest of the legislation, the entire
ACA would be struck down. If it is deemed
unconstitutional and severable, then the prohibitions
against excluding patients with pre-existing
conditions and charging higher premiums based on a
person's medical history also might be invalidated.
Chapter IX
The Education, Training and Accountability Gap
Compounding the profound gap between the
need for prevention, intervention, treatment and
disease management for addiction and the
receipt of such care is the enormous deficit of
trained providers; there is a wide gulf between
existing knowledge about addiction and its
prevention and treatment and the education and
training received by those who provide or should
provide care. In spite of the evidence that risky
use of addictive substances is a public health
problem and addiction is a disease:
• Most health professionals* are not
sufficiently trained to educate patients about
risky use and addiction, conduct screening
and interventions for risky use or diagnose
and treat addiction;
• Most of those who currently are providing
addiction treatment are not medical
professionals and are not equipped with the
knowledge, skills or credentials necessary to
prove the full range of evidence-based
services to address addiction effectively;* 1
and
The term "health professional" as used in this report
includes medical professionals (physicians, physician
assistants, nurses and nurse practitioners, dentists,
pharmacists) and graduate-level clinical mental
health professionals (psychologists, social workers,
counselors). All health professionals can be trained
to educate patients about risky use and addiction and
screen for these conditions; brief interventions also
can be conducted by appropriately trained health
professionals. Diagnosis and treatment requires a
trained physician with the exception of psychosocial
treatments which can be provided by trained
graduate-level clinical mental health professionals
working with a managing physician.
1 The National Quality Forum (2005) defines
evidence-based addiction care to include: screening,
brief interventions, treatment planning, psychosocial
interventions, pharmaceutical therapy, retention
strategies and chronic care management. Effective
implementation requires particular skills and training.
-175-
• Addiction treatment facilities and programs
are not adequately regulated or held
accountable for providing treatment
consistent with medical standards and
proven treatment practices.2
Further complicating the education, training and
accountability gap in addiction treatment is the
fact that there are no national standards; instead,
there is considerable inconsistency among states
in the regulation of individual treatment
providers and of the programs and facilities that
provide addiction treatment services.*
For just about all known diseases other than
addiction, treatment is provided within a highly-
regulated health care system. In contrast,
patients with the disease of addiction are
referred to a broad range of providers largely
exempt from medical training and standards (for
many of whom the main qualification may be
that they themselves have a history of addiction)
who work within a fragmented system of care
with inconsistent regulatory oversight.
The Size and Shape of the
Addiction Treatment Workforce
Given the extensive prevalence of addiction in
the U.S. and the frequently extensive treatment
needs of individuals with addiction, there is a
significant shortage of qualified addiction
treatment providers.3 According to data
collected from 1996 to 1997, there are 134,000
full-time staff and 201,000 total staff (including
part-time and contract staff) working in
addiction treatment. ' Only a small proportion of
these workers, however, have medical training.4
Trained medical professionals and other
graduate-level health professionals are less
likely than other types of providers to work full-
time in addiction treatment; rather, staff
members with higher levels of education are
more likely to be hired on a contract/part-time
basis.5 A nationally representative survey of
addiction treatment facilities found that one-
quarter of the program directors were not full-
time employees; only two of the programs
surveyed were directed by a physician; 54
percent employed a part-time physician; less
than 1 5 percent employed a nurse; and
psychologists and social workers rarely were on
staff.6 An older study1 found that medical
professionals and graduate-level counselors each
made up only about 17 percent of the full-time
staff of addiction treatment facilities and that
only 12.8 percent of facilities had a physician on
staff full time.§ 7 Another study found that more
than a third of clinical supervisors lack any type
of graduate degree.8
Unlike patient care in the mainstream medical
system, which is delivered by highly educated
and trained professionals, the staff primarily
responsible for patient care in addiction
treatment facilities is comprised largely of
addiction counselors, many of whom while
highly dedicated to addiction care have only a
bachelor's degree or, in some cases, no post-
high school education.9 The Bureau of Labor
Statistics reports that there were 76,600
addiction counselors in 201 1." 10 One study
found that 50 percent of facilities have full-time
counselors on staff who have no degree; 58.5
percent have a bachelor's level counselor, 61.9
percent have a master's level counselor and 12.0
percent have a doctorate level counselor. 1 1
With the notable exception of the regulation of
medication-assisted therapy for addiction involving
opioids.
* This estimate includes physicians, registered nurses,
other medical personnel, doctoral level counselors,
master's level counselors, counselors with other
degrees, non-degreed counselors and other staff.
Data on the numbers of professionals who currently
are providing some type of addiction treatment are
not available.
* Data are from 1996/1997.
§ 25.8 percent had a full-time registered nurse and
17.5 percent had other full-time medical staff.
Addiction counselors are those who "counsel and
advise individuals with alcohol, tobacco, drug or
other problems such as gambling and eating
disorders. May counsel individuals, families or
groups or engage in prevention programs." This
estimate excludes social workers, psychologists and
mental health counselors who provide these services.
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Even among physicians, who constitute the
group most qualified to treat patients with the
medical disease of addiction, required training in
addiction is minimal.12 And there is a severe
shortage of physicians with expertise in
addiction treatment via the medical specialty
fields of addiction medicine and addiction
psychiatry.13
The American Medical Association (AMA)
estimates that of the 985,375 active physicians,
there are only 582 addiction physician
specialists: 227 addiction medicine physicians
and 355 addiction psychiatrists —the two
medical sub-specialties specifically trained in
addiction science and its treatment— totaling
6/100ths of one percent of all active
physicians.14 However, according to the
American Board of Addiction Medicine
(ABAM), these estimates are low since they
come from a voluntary, self-report survey in
which physicians who choose to respond are
asked to indicate their specialty and typically
mark the field of their primary board
certification rather than their subspecialty.15
Although there are no recent data identifying the
actual number of practicing specialists in
addiction medicine or addiction psychiatry,
ABAM has certified 2,584 addiction medicine
specialists and estimates that the number of full-
time practicing addiction medicine specialists
may be about five times the amount of the AMA
estimate— approximately 1,200.' 16 This estimate
still falls far short of the estimated minimum of
6,000 full-time addiction medicine specialists
currently needed to meet addiction treatment
demands.17 Even this projection of workforce
need in addiction medicine may underestimate
the need in several ways: (1) it does not include
adolescents; (2) it does not include addiction
involving nicotine;* (3) it does not include
institutionalized individuals; (4) it assumes that
only those who meet clinical criteria for
Based on data from 2010.
1 Data on the number of practicing addiction
medicine specialists who are involved directly in
patient care are not available.
* Unless addressed in the context of addiction
involving alcohol or other drugs.
substance dependence as distinguished from
substance abuse require any form of specialty
care; and (5) it is based on data that are six years
old.18 Adjusting ABAM's estimate to address
these gaps could increase substantially the
number of addiction medicine specialists
required to provide needed care.
Likewise, due to the limitations of the AMA
survey and the absence of other data, it is
impossible to know how many of the 1,137
physicians who are board certified in addiction
psychiatry as of 201 1 19 currently are practicing
in that subspecialty or how much overlap there
is with the number of physicians certified in
addiction medicine.
Licensing and Credentialing
Requirements for Individuals who
Provide Addiction Treatment5
To help assure adherence to minimum standards
in the delivery of medical care, the licensing and
credentialing requirements of individuals who
may provide such care are clearly delineated and
regulated. For physicians, these include
extensive graduate-level classroom-based and
clinically-supervised training, a focus on
s The information provided in this section is based on
an extensive review of publicly available documents
conducted by CASA Columbia in 2010. This
entailed online reviews and updates (using the
Internet and the Lexis/Nexis database) of publicly-
available federal and state laws and regulations (in all
50 states and the District of Columbia) and of
professional association Web sites. CASA
Columbia's analysis examined the minimum
licensing and certification requirements to practice in
each profession in the 50 states and the District of
Columbia, and optional certifications. The analysis
sought to develop a summary overview of the
regulatory landscape. However, because licensing
and certification requirements are found in a wide
variety of laws and regulations and can change on a
state by state basis, and may have changed in certain
states since the time of the review, findings from this
review cannot be guaranteed to be complete and
current. Unless cited to another source, the findings
presented regarding licensing and certification
requirements are derived from this review. See
Appendix A for a description of the methodology.
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standards of medical practice and the adoption
of evidence-based practices for those who wish
to become board certified.21 In contrast, there
are no clearly delineated, consistent and
regulated national standards that stipulate who
may provide addiction treatment in the United
States; instead, standards vary by payer and by
state.
In 2010, CASA Columbia examined the
addiction-related licensing and certification
requirements of individuals who most typically
are the providers of addiction treatment and
related services in the United States. These
include medical professionals such as
physicians, physician assistants, nurses and
nurse practitioners; mental health professionals
such as psychologists, social workers and
counselors/therapists; acupuncturists; and
addiction counselors. Licensure is a mandatory
process required by state law; licensing
standards are designed to ensure minimum
competency required to practice one's
profession and protect public health, safety and
welfare. Certification is a voluntary process
administered by non-governmental
organizations, typically professional
associations.22 Certification demonstrates
additional expertise within a specific area of
one's profession (i.e., a specialty).23
Of all these groups, addiction counselors provide
the majority of addiction treatment in the U.S.24
Indeed the only category of providers
specifically required to be licensed to provide
addiction treatment in most states is addiction
counselors. Yet the requirements in some states
for becoming an addiction counselor include
only a high school diploma and some practical
training-typically involving a focus on the 12-
step model.25 Training approximates an
apprenticeship model which may fail to promote
systematic adoption of evidence-based
practices.26 Historically, personal experience
with addiction (i.e., being "in recovery") was the
primary qualification necessary to become an
addiction counselor.27
Unlike providers of medical care who are trained
in evidence-based medical practices, few among
the broad range of providers who may treat
patients with addiction are trained in or
knowledgeable about evidence-based practices
in addiction prevention and treatment.28 While
medical professionals and some mental health
professionals may have the training and skills
needed to implement research-based treatments-
-and regularly come into contact with patients in
the target population of risky substance users
and those with addiction—most are unprepared
to address these conditions. And while
addiction counselors, who constitute the largest
proportion of the workforce in specialty
treatment facilities, 29 specifically address
addiction, most lack an education grounded in
the science of addiction and are not equipped to
deliver evidence-based treatments including
appropriate medical care and treatment of co-
occurring health conditions.30
Compounding this problem is that the diversity
in education and training among the different
types of individuals providing addiction
treatment results in inconsistent treatment
approaches and care for patients with
addiction.31
Medical Professionals
Medical professionals have been regulated at the
state level since Colonial times.32 Rooted in
their police powers, states have the authority to
prohibit the performance of ineffective and
dangerous treatments, to license professionals
and to define their scope of practice.33 For
specific licensing standards, states largely defer
to professional boards and national organizations
that accredit education programs. Medical
professionals must complete an accredited
professional education program and pass a
national licensing exam to become licensed by
the state in which they practice their profession.
State licensing requirements may include
minimum education, training or skills
demonstrated by earning a specified degree;
time spent in clinical training requirements; and
passing a licensing exam.
Because risky use of addictive substances is a
public health issue and addiction is a medical
condition, medical professionals-particularly
physicians-should be on the front lines in
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treating patients with these conditions, working
with a team of other qualified health
professionals. However, separate courses in
addiction medicine rarely are taught in medical
school34 and there are no addiction medicine
residencies among the 9,034 accredited U.S.
residency programs currently training 1 16,404
residents.35 Physicians, therefore, lack the basic
education and training in addiction medicine that
is needed to understand the science of addiction,
translate research evidence into practice, screen
for risky use, diagnose and provide treatment for
addiction and the broad range of co-occurring
health problems, or refer patients to other
specialists as needed.36
Physicians. To become a physician, an
individual must earn a bachelor's degree,
complete four years of medical school to earn an
M.D. (allopathic physician) or a D.O.
(osteopathic physician) and complete an
additional three to seven years of post-graduate
training in a medical residency training program
(also called graduate medical education).37 To
become licensed to practice medicine,
physicians must pass a three-step licensing
exam; allopathic candidates take the United
States Medical Licensing Exam (USMLE).38
The USMLE includes addiction as a possible
subtopic in each step.* 39 Those who choose to
practice osteopathic medicine must take the
Comprehensive Osteopathic Medical Licensing
Examination (COMLEX) administered by the
National Board of Osteopathic Medical
Examiners (NBOME).40 Dimension 1 of the
COMLEX exam is devoted to "Patient
Presentation" where addiction is listed as a
subtopic' 41 These requirements are set by
national accreditation organizations (that
accredit schools and residency programs) and
professional boards (that provide education and
licensing standards) to which states defer when
they require professional licensing.42
Within the content areas "Central and Peripheral
Nervous Systems: Abnormal Processes" in Step 1 of
the exam, "Mental Disorders" in Step 2 and
"Behavioral/Emotional Disorders" in Step 3.
f Within the content areas "Population Health
Concepts: Disease Detection and Monitoring" and
"Cognition, Behavior, Sensory and Central Nervous
Systems, Substance Abuse and Pain."
Although physicians in the United States have
extensive competency requirements regarding
most illnesses, their level of required
competency in addiction medicine is minimal
given the prevalence of risky substance use and
addiction in most patient populations.43 No
reliable national data exist on the proportion of
medical school curricula devoted to the topic of
addiction. A national survey of residency
training program directors in seven medical
specialties revealed that 56.3 percent of the
programs report having required curriculum
content in preventing and treating addiction, but
that the median number of curricular hours of
training ranges from three (emergency medicine
and obstetrics/gynecology) to 12 (family
medicine).44 While most allopathic medical
schools do include some addiction content in
required coursework,45 research suggests that the
average school requires few hours of its four-
year curriculum to be devoted to the topic.46
Physicians may choose to become board
certified in a medical specialty, which
demonstrates that they have the knowledge,
skills and experience to treat patients within that
specialty.47 The American Board of Medical
Specialties (ABMS) has adopted a Maintenance
of Certification (MOC) program for all
specialties in which physicians must stay abreast
of the latest advances in their specialty and
demonstrate use of best practices.48
CASA Columbia reviewed the board
certification exam requirements of the six
medical specialties that interact most often and
regularly with patients who engage in risky
substance use or have addiction to determine
their addiction-related content:
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• Internal Medicine- two percent of the
general board exam.49 In addition,
substance use/addiction is listed as possible
subtopics in the geriatric medicine* 50 and
infectious disease51 subspecialty exams;
however, the exact proportions are not
specified.
• Pediatrics- 1.5 percent of the general
exam,52 five percent of the adolescent
medicine exam53 and two percent of the
developmental-behavioral pediatrics
subspecialty exam.54 Substance-related
topics also are listed in the pediatric
emergency medicine, child abuse pediatrics,
and neonatal-perinatal medicine
subspecialty exams; however, the exact
proportion is not specified.55
• Family Medicine-no specification in the
general board exam,56 but the pharmacology
of and testing for the use of addictive
substances is included as a possible subtopic
in the optional sports medicine subspecialty
certification exam.57
• Psychiatry— included as subtopics in the
general board exam, but the proportion of
the total content is not specified.58 Also
one-half percent of the forensic psychiatry
and six percent of the psychosomatic
medicine subspecialty exams are devoted to
substance use/addiction.59 Substance
use/addiction also is listed as a subtopic in
Subspecialty certifications in the same area may be
offered by more than one medical board. For
example, the geriatric medicine subspecialty
certification administered by the American Board of
Internal Medicine also can be obtained by physicians
specializing in family medicine; the adolescent
medicine certification administered by the American
Board of Pediatrics also can be obtained by
physicians specializing in internal medicine and
family medicine; the pediatric emergency medicine
exam administered by the American Board of
Pediatrics also can be obtained by physicians
specializing in emergency medicine; and the sports
medicine subspecialty certification administered by
the American Board of Family Medicine also can be
obtained by physicians specializing in internal
medicine, pediatrics and emergency medicine.
the child and adolescent psychiatry, geriatric
psychiatry and pain medicine subspecialty
exams.60
• Emergency Medicine— included as a subtopic
in the qualifying examination, although the
exact proportion and content are
unspecified.61
• Obstetrics/Gynecology— included in a
subtopic of the general written board
certification exam, although the exact
proportion is unspecified. Substance
use/addiction assessment and counseling are
listed as one of 40 patient cases that may be
covered in the oral exam.62 The
subspecialty of maternal- fetal medicine
explicitly lists substance use/addiction as a
competency for the certification exam, but
the exact proportion and content are
unspecified.63
There are two areas of specialty medical practice
in addiction: addiction medicine and addiction
psychiatry.
Addiction Medicine. The American Board of
Addiction Medicine (ABAM) offers a voluntary
certification in addiction medicine to physicians
across a range of medical specialties.64 The role
of the addiction medicine physician, as a
member of an interdisciplinary team of health
professionals, includes examining patients to
establish the presence or absence of a diagnosis
of addiction; assessing associated health
conditions that are brought on or exacerbated by
the use of addictive substances; participating in
the development and management of an
integrated treatment plan; prescribing and
monitoring patients' use of addiction treatment
medications and therapies; providing direct
treatment and disease management for
individuals with severe cases of addiction and
providing consultation to other primary and
specialty care providers.65 To become certified
in addiction medicine, applicants must meet
specific educational and clinical requirements
including:
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• Graduating from a medical school in the
U.S. or Canada approved by the Liaison
Committee on Medical Education (LCME)
or the Committee on Accreditation of
Canadian Medical Schools (CACMS) or
from a school of osteopathic medicine
approved by the American Osteopathic
Association (AO A);* 66
• Being an ABMS board-certified physician
or having completed a residency training
program' in any medical specialty, plus 50
hours of addiction medicine educational
course work (continuing medical
education/CME);67
• Completing at least 1 ,920 hours in teaching,
research, administration and clinical care
related to prevention and treatment for
individuals who are at risk for or have
addiction, or completing a one-year ABAM
Foundation-accredited addiction medicine
residency training program;68
• Passing a five and a half-hour computer-
based examination;69 and
• Holding a valid and unrestricted license to
practice medicine in the United States, its
territories or Canada.70
Physicians must maintain their certification
through ABAM's Maintenance of Certification
(MOC) program of continuing education and
periodic examinations.71
If applicants are graduates of medical schools
outside the U.S. or Canada, they must have a
currently valid standard certificate from the
Educational Commission for Foreign Medical
Graduates (ECFMG) or have passed the Medical
Council of Canada Evaluating Examination
(MCCEE).
1 Residency programs must be accredited by one of
the following: the Accreditation Council for Graduate
Medical Education (ACGME), the Royal College of
Physicians and Surgeons of Canada, the Professional
Corporation of Physicians of Quebec or residency
programs accepted by any member board of the
American Board of Medical Specialties (ABMS) as
qualifying to sit for that member board's certification
examination.
Though not yet a member board of the ABMS,
ABAM is working to gain recognition of
addiction medicine as a medical specialty.72
Addiction Psychiatry. The American Board of
Psychiatry and Neurology, Inc. offers optional
certification in addiction psychiatry. Addiction
psychiatrists are trained to identify and treat co-
occurring addiction and psychiatric disorders in
individuals seeking treatment for either
condition, and in therapies tailored to specific
subgroups of patients with addiction.73
Addiction psychiatry is recognized by the
ABMS.74 Candidates for certification are board-
certified psychiatrists who have completed a
one-year fellowship in addiction psychiatry.75
Physician Assistants. Physician assistants are
licensed to assist physicians in the practice of
medicine, enabling them to perform many of the
same duties that physicians perform, including
medical assessments and prescribing
medication.76 The precise scope of their practice
varies according to the regulations of each state.
All states license and regulate physician
assistants and require graduation from an
accredited physician assistant's program and
passing of the Physician Assistant National
Certifying Examination (PANCE) administered
by the National Commission on Certification of
Physician Assistants (NCCPA).77 States defer to
the national accreditation agency and
professional board for content requirements. All
physician assistants must complete two years of
college course work in basic and behavioral
sciences and earn a degree from a program1
accredited by the Accreditation Review
Commission on Education for the Physician
Assistant (ARC-PA).78 Most programs (more
than 80 percent) award a master's degree.79
1 Physician assistant programs are approximately 27
months long.
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The ARC-PA requires physician assistant
programs to provide some instruction in the
"detection and treatment of substance abuse"
although the nature and extent of this instruction
is not specified.80 The PANCE exam may
include addiction in its psychiatry^ehavioral
exam category.* 81
As of 2010, all states permit physicians to
delegate prescription privileges to physician
assistants82 and all states except Florida and
Kentucky allow physician assistants to prescribe
certain controlled substances under medical
supervision.83 Yet physician assistants, like
other medical professionals, receive little
training in addiction in spite of the fact that they
can prescribe controlled substances. *
Nurses. States offer several categories of
licensing in the nursing profession, each with
different standards, practice limitations and
supervision requirements. As they do for
physicians, states defer to national accreditation
agencies and professional boards for specific
licensing standards for nurses. To be a licensed
registered nurse (RN), one must graduate from
an accredited nursing program which includes
earning either a bachelor's of science degree in
nursing (BSN), an associate's degree in nursing
(ADN) or completing a diploma program
(administered in hospitals).84 Graduates from
each program are eligible to take the National
Council Licensure Exam (NCLEX),
administered by the National Council of State
* Each question addresses one organ system along
with one of seven practice areas: history taking and
physical examinations, using laboratory and
diagnostic studies, formulating a most likely
diagnosis, health maintenance, clinical interventions,
pharmaceutical therapeutics and applying basic
science concepts.
t A few states require physician assistants to be
trained in addiction. Physician assistants in CA who
wish to prescribe controlled substances without
advanced approval from a supervising physician are
required to take a controlled substance education
course which includes assessment of risky substance
use and addiction. In OK, all physician assistants
must complete one hour of continuing education per
year on the topic of addiction.
Boards of Nursing, and they must pass this exam
to become a licensed RN.85
Even though most nurses interact regularly with
individuals who are risky users or who have
addiction,86 CASA Columbia's review found
that in all but several states1 addiction-related
education is not required explicitly in curriculum
guidelines for state nursing programs. Other
research found that many nursing education
programs do not teach current information
related to addiction.87 The National League for
Nursing Accrediting Commission and the
Commission on Collegiate Nursing Education,
the two main accrediting agencies for nursing
schools, do not require addiction to be part of
nursing curricula.88 Addiction, including the
topic of smoking cessation, may be included as
topics on the licensing exams for registered and
practical/vocational nurses.89 The American
Academy of Nursing recently published new
core clinical competencies in mental health that
should be expected of all RNs. They include
knowledge about the disease of addiction,
addiction treatment, the pharmacology of
commonly-misused illicit and prescription
drugs, comprehensive screening, motivational
interviewing, patient outcome evaluation,
comprehension of research literature and the
adoption of evidence-based practices.90
In most states, advanced practice nurses (APN)
must earn a master's degree and are authorized
to prescribe both non-controlled and controlled
substances;91 however, few states explicitly
include addiction-related content in their training
requirements.
The International Nurses Society on Addictions
(IntNSA) offers an optional certificate in
addiction nursing; to qualify, candidates must
1 In CA, RNs must complete studies in alcohol and
other drug addiction; however, the exact amount is
not specified. In IL, programs in practical nursing
must include a course in pharmacology which must
include topics on substance use and addiction. IN
and RI require some addiction education and NJ
requires six contact hours in pharmacology related to
controlled substances including the prevention and
management of addiction involving these substances.
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have 200 hours (one year) of addiction-specific
experience as an RN and pass an examination.92
Mental Health Professionals
As is true of medical professionals, the licensing
of mental health professionals is regulated by the
states, which defer to national accreditation
organizations and professional boards.
Psychologists. Licensed clinical and counseling
psychologists must obtain a doctorate degree
from a PhD or PsyD program at an accredited or
government-chartered institution acceptable to
the American Psychological Association (APA)
licensing board.93 They also must pass a
national licensing examination, the Examination
for Professional Practice in Psychology,
administered by the Association of State and
Provincial Psychology Boards.94 Vermont and
West Virginia offer a psychologist license at the
master's level*
In the course of their practice—whether in the
mental health care system, the general health
care system, the correctional system, schools
and universities or specialty addiction treatment
programs— clinical and counseling psychologists
encounter many patients who engage in risky
substance use or have addiction. Psychologists
often hold administrative and supervisory
positions in specialty addiction treatment
programs and other health and social welfare
systems with large numbers of substance-
involved individuals.95 Yet CASA Columbia's
review found that in most states, addiction is not
a required element of psychologists' training. '
In the national licensing exam for
psychologists, addiction-related content may
appear as part of the required knowledge base in
A number of states also license temporary or
renewable psychological associate licenses for
master's level supervised practitioners.
* CA requires all licensed psychologists to have some
level of addiction-related education; applicants must
complete at least a semester course in addiction
detection and treatment.
* The Examination for Professional Practice in
Psychology, administered by the Association of State
and Provincial Psychology Boards (ASPPB).
several content areas, including "biological
bases of behavior" and "assessment and
diagnosis. "§ 96
The APA had offered an optional certificate
related to substance use and addiction which,
although recognized by some state agencies,
was not required for a psychologist to treat
patients with addiction; the only requirement for
this certification was experience in treating
addiction as a licensed psychologist for at least
one year.97 As of January 1, 201 1, the APA
Practice Organization (APAPO) discontinued
accepting new applications for the Certificate of
Proficiency in the Treatment of Alcohol and
Other Psychoactive Substance Use Disorders but
continues to support the credential for
previously-certified psychologists who maintain
their certification by engaging in appropriate
continuing education. The decision to
discontinue the certification program for new
applicants was based in part on insufficient
interest in obtaining the credential by licensed
98
psychologists.
Mental Health Counselors/Therapists. All
states license mental health counselors99 and,
with the exception of the "professional
counselor" license in Illinois, ft all states require
at least a master's degree in counseling or a
related field.
The National Board for Certified Counselors
(NBCC) offers certification to become a
National Certified Counselor (NCC); in
addition, three optional national specialty
certifications are offered on the graduate level to
become a school counselor, clinical mental
§ Although these content areas constitute 40 percent
of the test, the exact proportion of substance
use/addiction content is not specified.
There are a number of different ways that state
agencies have recognized the certificate. Most states
use it as one way for psychologists to be listed as
registered addiction treatment providers or as one
way to qualify them as clinical supervisors. The
significance of these categories depends on the state's
regulations.
^ IL requires only a bachelor's degree. IL also has a
"clinical professional counselor" license which
requires a master's degree.
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health counselor and master addictions
counselor.* 100 The National Counselor
Examination for Licensure and Certification
(NCE), administered by NBCC, is required for
those seeking certification. The NCE exam does
not appear to contain substance use/addiction-
related content;101 however, the specialty
certification exam administered by the NBCC
for the master addictions counselor exam
focuses on addiction.102 The master addictions
counselor certification requires (1) a minimum
of 12 semester hours of graduate coursework in
addiction content or 500 continuing education
hours in addiction content; (2) three years of
supervised experience as an addiction counselor
at a minimum of 20 hours per week (two of the
three years must have been completed after
obtaining the master's degree in counseling);
and (3) a passing score on the examination for
master addictions counselor.103 National
certification is voluntary; however, in some
states, counselors are exempt from taking a state
certification exam if they pass the national
104
exam.
Professional counselors are trained to provide
treatment for mental, emotional and behavioral
disorders and tend to encounter in their practice
individuals who engage in risky substance use or
have addiction.105 Although risky substance use
and addiction may be addressed under broad
course content areas, CASA Columbia's review
found few explicit state licensing requirements
that mandate a specific number of addiction-
related education hours in their curriculum
guidelines.1
The Council for Accreditation of Counseling
and Related Educational Programs (CACREP),
which accredits master's programs in numerous
counseling specialties, requires all programs to
provide students with an understanding of
"theories and etiology of addictions and
addictive behaviors, including strategies for
The NCC is a pre- or co-requisite for the specialty
credentials.
1 More frequently, states mention substance use and
addiction as topics that may be addressed under
content areas such as human growth and development
or that may be taken as electives or continuing
education courses.
prevention, intervention and treatment." The
CACREP specifically includes additional
substance-related content in the curricular
requirements for clinical mental health
counseling; marriage, couple and family
counseling; school counseling; and student
affairs and college counseling programs.106
Surveys of these programs reveal, however, that
the majority of CACREP-accredited master's
programs in counseling offer elective courses
but do not require substance use/addiction-
related course work. When asked to identify
which courses teach addiction-related content,
CACREP programs typically cite supervised
clinical settings (practicums and internships),
where students encounter patients who engage in
risky substance use or have addiction, rather
than classroom-based courses. Most counseling
degree programs do not provide any addiction
education prior to the clinical experience.107
Marriage and Family Therapists. Marriage and
family therapists either must have a master's
degree, a doctoral degree or three to four years
of post-graduate clinical training for licensure.108
According to CASA Columbia's review, few
states have explicit addiction-related education
requirements (such as minimum number of
hours of addiction content); most states that
mention addiction include it as an optional or
suggested topic or as a topic eligible for
continuing education credit. The national
licensing exam in Marital and Family Therapy is
administered by the Association of Marital and
Family Therapy Regulatory Boards (AMFTRB).
In drafting the Examination in Marital and
Family Therapy, the Examination Advisory
Committee draws from a list of the 56
knowledge areas required for entry- level
practice in marital and family therapy, which
includes two areas related to substance use and
addiction.1 109
Social Workers. Some social workers function
as mental health professionals, providing
counseling services. Social workers must earn,
1 The substance-related areas in the AMFTRB are
"effect of substance abuse and dependence on
individual and family functioning" and "addiction
treatment modalities."
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at a minimum, a bachelor's degree in social work
(BSW); however, a master's degree in social
work (MSW) often is required for positions in
health care settings or to provide clinical
services.110
The Association of Social Work Boards
(ASWB), which regulates the profession,
administers four separate examinations: the
bachelor's exam, master's exam, advanced
generalist exam and clinical exam. Each state
determines the examination required for
licensure.
More than 25 percent of patients whom social
workers come into contact with either have a
primary or secondary diagnosis of addiction.111
While addiction-related content is mentioned
explicitly as a topic area that may be included in
the bachelor- and clinical-level licensing
examinations,112 CASA Columbia's review
identified just two states— California and Alaska-
-that require social workers to complete
coursework in addiction. ' 113
The National Association of Social Workers
offers an optional Certified Clinical Alcohol,
Tobacco, and Other Drugs Social Worker (C-
CATODSW) certification for master's level
social workers with 180 hours of addiction-
related education and two years of paid,
supervised post-graduate work experience in
both clinical social work and addiction
counseling. * 114
In general, the bachelor's exam is designed for
those with a BSW and no post-degree experience; the
master's exam is for those with an MSW and no post-
degree experience; the advanced generalist exam is
for those with an MSW and at least two years of post-
degree experience in non-clinical settings; and the
clinical exam is for those with an MSW and at least
two years of post-degree experience in direct clinical
practice settings.
* In CA, the applicant must obtain at least 15 hours of
addiction-related training. In AK, licensed social
workers must complete 45 hours of continuing
education, including six hours of addiction-related
education during their bi-annual license renewal
cycle.
* Nationwide data on the number of practicing social
workers with this certification are not available.
Acupuncturists
Acupuncture sometimes is used as an
alternative/complementary treatment for
addiction. Estimates are that several hundred
addiction treatment clinics in the U.S. and
Europe offer auricular acupuncture, a procedure
that targets chronic diseases, including addiction
through needle therapy of the ear (typically used
to treat cocaine addiction).115 Despite its
widespread use, there is very little research
supporting the efficacy of auricular acupuncture
for the treatment of addiction.116
CASA Columbia's review found that most states
require individuals who practice acupuncture to
be licensed. Licensing requirements include
earning a degree from an accredited acupuncture
school and, except in four states, professional
certification or examination by the National
Certification Commission for Acupuncture and
Oriental Medicine (NCCAOM). In Alabama
and North Dakota, which do not have licensure
requirements for acupuncturists, only
physicians, osteopaths or chiropractors may
practice acupuncture as permitted by their scope
of practice or via specialty certification.5 117
CASA Columbia's review identified several
states that require specialized training and
certification to practice auricular acupuncture.
In California, acupuncture training programs are
required to teach both auricular acupuncture and
principles of public health, including treatment
of addiction.118 Acupuncturists certified through
NCCAOM for Acupuncture and Oriental
Medicine are not required explicitly to have
addiction-related training, although substance-
related knowledge is in the exam content for the
"diplomate in acupuncture" certification.119 The
National Acupuncture Detoxification
Association (NAD A) 120 certifies Acupuncture
s In KS, acupuncturists may practice under the
supervision of a medical doctor, osteopath or
chiropractor. In OK, medical doctors may practice
acupuncture. In SD, chiropractors may practice
acupuncture. WY has no laws or regulations
permitting or prohibiting acupuncture practice.
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Detoxification Specialists (ADS) and has its
own set of training guidelines.* 121
Addiction Counselors
Addiction counselors, also known as Substance
Abuse Counselors (SACs), Credentialed
Alcoholism and Substance Abuse Counselors
(CASACs) or Alcohol and Drug Counselors
(ADCs), make up the largest share of full-time
addiction treatment provider staff in facilities
providing addiction treatment in the United
States.122
Addiction counselors can be licensed, certified
or both.123 CASA Columbia's review found that
37 states require addiction counselors either to
be licensed or certified, although even these
states may provide important exemptions. '
The review also found that to become a licensed
addiction counselor in a given state, generally
one must meet the state's minimum education
and training requirements and pass a designated
exam. There is no one national licensing exam
used to measure competencies.124 The state
education qualifications for licensure vary
greatly/ 125 According to CASA Columbia's
review, more than half of states that offer
licensing require a master's degree for the
The NADA training guidelines include 30 hours of
didactic classroom training (e.g., history of the
profession; the NADA protocol which defines the
five points where needles are to be applied;
techniques; clean needle; integration with larger
treatment program; ethics) and 40 hours of hands-on
clinical work (content not specified), supervised by a
licensed acupuncturist.
' Such as supervised students engaged in practicum,
licensed health care professionals (e.g., MDs, RNs,
psychologists) working within their scope of
profession, religious leaders working within the
scope of their ministerial duties, government
employees working within the scope of their
employment, and short-term services provided by
non-residents who are certified in another state.
* There are several tiers of addiction counselors— such
as Certified Alcohol and Drug Abuse Counselor
(CADAC) or Substance Abuse Counselor (SAC)-
each with its own proficiency requirements (based on
education and experience). The highest level usually
requires a master's or doctorate degree.
highest level of licensure, although several states
offer the highest level of licensure to individuals
who only have a bachelor, associate or high
school degree. A 1998 survey similarly found
that 56 percent of licensed addiction counselors
have at least a master's degree.126
A variety of state boards and non-governmental
organizations are designated with responsibility
for certifying addiction counselors.127 Similar to
the licensure process, certification recognizes
that addiction counselors have met what the
organization deems to be minimum standards of
education and clinical experience.128 In some
states addiction counselors must be certified
while in other states certification is voluntary.129
Some state certification boards defer to
standards established by professional
membership or credentialing organizations, such
as the International Certification and Reciprocity
Consortium (IC&RC) or NAADAC, the
Association for Addiction Professionals,5 130
which do not stipulate a particular required
degree for the entry level certification.131
The IC&RC establishes minimum education and
training standards for the credentialing of
addiction counselors— each state certification
board that is a member of the IC&RC
consortium either may follow the minimum
standards or impose higher standards.132 The
focus of the minimum requirements for the
IC&RC Alcohol and Drug Counselor (ADC)
certification is more on clinical work experience
than on classroom-based education:
requirements include 270 hours of education in
the eight domains of addiction counseling, 300
hours of supervised practical experience in the
eight domains, 6,000 hours of supervised
s The National Association for Alcoholism and Drug
Abuse Counselors (NAADAC) changed its name in
2001 to NAADAC, the Association for Addiction
Professionals to reflect the increasing number of
addiction professionals who address forms of
addiction involving behaviors other than substance
use, such as gambling.
The eight domains include: clinical evaluation;
treatment planning; referral; service coordination;
counseling; client, family and community education;
documentation; and professional and ethical
responsibilities.
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professional work experience specific to the
eight domains and successful completion of a
1 33
written examination.
NAADAC, the Association for Addiction
Professionals offers three levels of certification
for addiction professionals based on experience
and education.134 Like the IC&RC requirements
for the National Certified Addiction Counselor,
Level I (NCAC I), the focus primarily is on
clinical work experience rather than on
classroom-based education. Requirements
include: (1) a current state certificate or license
as an addiction counselor; (2) 270 contact hours
of addiction counseling training; (3) three years
of full-time work experience or 6,000 hours of
supervised experience as an addiction counselor;
and (4) successful completion of a written
examination.
These certification requirements reflect a great
reliance on apprenticeships as the training model
for addiction counselors.136
CASA Columbia's state-by-state analysis of
regulations and statutes found that 14 states do
not require addiction counselors in all settings to
be licensed or certified. Six states do not
mandate any degree to become credentialed as
an addiction counselor;1 in 14 states, an
individual may become licensed or certified as
an addiction counselor with the minimum
education requirement of a high school diploma
or a GED; an associate's degree is required in 10
In AR, counselors who are not licensed or certified
must register with the state; CT, FL and NY do not
require supervised staff and MA does not require
staff in licensed facilities to be licensed or certified;
ID, MS, OR, and SD require licensing or certification
of counselors only in certain facilities (e.g., licensed
facilities or those that receive public funds); HI
insurance law requires clinical licensure and
certification to qualify for reimbursement; in MO,
staff who are not licensed or certified have a limited
scope of practice; in WV, only counselors in opioid
treatment facilities must be certified or licensed; and
AK and NH do not appear to require counselors to be
licensed or certified.
' In states where no degree is required, certification
requirements typically include 270 hours of
education in addiction counseling.
states, a bachelor's degree is required in six
states and a master's degree is the minimum
requirement in only one state.*
CASA Columbia's survey of New York State
addiction treatment staff providers found that
35.0 percent had a graduate degree, 27.7 percent
had a bachelor's degree, 29.9 percent had some
college or an associate's degree and 6.6 percent
had only a high school or GED degree.137
In spite of the limited education and training
requirements and the apprenticeship model of
training, the essential practice dimensions of
addiction counseling are defined as including
clinical evaluation; treatment planning; referral;
service coordination; and individual, group,
family and couples counseling138— practices that
would seem to require far more extensive and
structured clinical training than the field of
addiction counseling requires.
Licensure, Certification and
Accreditation Requirements for
Addiction Treatment Programs and
Facilities
Just as licensing and certification requirements
are insufficient to assure that those providing
addiction treatment have the knowledge and
skills to do so, government and professional
oversight of addiction treatment facilities and
programs is insufficient to insure that patients
receive clinically-indicated, quality care.
Regulatory oversight of health care facilities
may include state licensure, certification^ and/or
accreditation by a national accrediting
organization. Licensing and certification
standards may include:
1 CASA Columbia reviewed the minimum education
requirements for certification/ licensure in each state.
In many states, counselors who meet only the
minimum education requirements must be
supervised.
§ In the case of opioid maintenance therapy.
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• Professional staffing requirements to assure
that clinical staff are adequately qualified to
implement evidence-based practices;
• Requirements related to services to be
delivered; or
• Requirements that treatment services
actually help patients achieve desired
outcomes of improved health and
functioning.139
Like health care facilities, addiction treatment
programs are subject to state licensing
requirements; however, for addiction treatment
programs, these requirements typically are set by
state agencies separately charged with authority
to oversee addiction services rather than by the
agencies responsible for regulating health care
facilities.140 CASA Columbia's review of
licensing and certification requirements for
addiction treatment facilities and programs '
found that the nature and extent of these
regulations vary significantly among states and
that certain addiction treatment programs (e.g.,
many state-run and religious programs) are
exempt entirely from state regulation. In
facilities that are subject to state regulation, the
staffing requirements do not consistently
mandate the involvement of professionals who
are capable of providing a full range of effective
interventions (including pharmaceutical and
psychosocial therapies), services rarely are
required to reflect best practices and quality
Including (1) organizations or facilities that provide
non-hospital based residential or outpatient addiction
treatment, or opioid replacement therapy (e.g.,
methadone maintenance clinics) and (2) hospital-
based inpatient and outpatient addiction treatment
programs.
1 This entailed online reviews and analyses of
publicly available documents related to federal and
state laws and regulations (in all 50 states and the
District of Columbia), including the use of the
Lexis/Nexis database to supplement information
related to state laws and regulations available on the
Internet. Because licensing and certification
requirements are found in a wide variety of laws and
regulations and can change on a state by state basis,
findings from this review cannot be guaranteed to be
complete and current.
assurance requirements seldom stipulate that
patient outcome data be collected, analyzed or
made available to the public. For no other
health condition are such exemptions from
routine governmental oversight considered
acceptable practice.
State Licensing Requirements
Health care facilities such as hospitals and
ambulatory care (outpatient) clinics are licensed
by state departments of health, whereas the
licensing authority for addiction treatment
facilities and programs is distributed across a
variety of governmental agencies and the
content of statutes and regulations varies greatly
by state.141
Most (81.9 percent) addiction treatment facilities
and programs that voluntarily participate in a
national survey of such providers1 are licensed
by the state agency responsible for addiction
services (which varies from state to state): 41.4
percent of facilities are licensed by the state
department of health; 35.3 percent by the state
mental health department; and 7. 1 percent by the
hospital licensing authority.5 142
Despite the abundant evidence that addiction
and mental health conditions co-occur at very
high rates and are best addressed in an integrated
manner, in some states, treatment facilities and
programs cannot be dually licensed to provide
both mental health and addiction treatment
143
services.
1 The National Survey of Substance Abuse Treatment
Services (N-SSATS) of the Substance Abuse and
Mental Health Services Administration (SAMHSA)
is a national survey of public and private addiction
treatment programs and facilities in the United States,
excluding treatment programs in jails and prisons.
Participation is voluntary and the survey does not
represent all treatment providers.
§ These categories are not mutually exclusive. More
than half (57.7 percent) of the addiction treatment
facilities that participate in the survey are not
licensed either by the state department of health or
the hospital agency— the two departments responsible
for licensing health care facilities.
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A significant number of states exempt state
agency-run programs (e.g., in the justice and
welfare systems) from licensure. A national
study of state-run treatment programs found that,
excluding programs provided or operated by the
state addiction treatment agencies, only about
one-half of state agencies that operate treatment
programs require the programs they operate to
meet state licensure standards:144
• 38 states report that the department of
corrections operates treatment programs, but
only 1 8 of these require treatment programs
operated by the corrections departments to
meet state licensing standards.* 145
• 1 3 states report that their juvenile justice
system operates treatment programs, with
only six states requiring these programs to
adhere to state licensing standards.146
• Seven states identify their departments of
child and family services as operating
treatment programs, with only four requiring
adherence to state licensing standards.147
• 18 states identified 2 1 other government
agencies (e.g., departments of public
welfare, mental health and criminal justice-
related agencies other than the department of
corrections) that operate treatment
programs, but in only 1 1 states are these
programs required to adhere to state
licensing standards.148
CASA Columbia also found substantial
inconsistencies in the regulation of faith-based
programs that offer addiction-related services.
While most states do not appear explicitly to
address faith-based programs in their laws or
regulations, some states explicitly exempt such
programs from regulation^
Federal Regulatory Requirements
The federal government does not regulate
addiction treatment facilities or programs, with
the exception of those that provide opioid
maintenance therapy. 149 However, the federal
government imposes certain conditions of
participation on qualifying programs and
facilities through federal health insurance
programs, including Medicare, Medicaid,
TRICARE for members of the active duty
military and the veterans' health insurance
program (CHAMP VA)— whether they are
mainstream health care or addiction treatment
providers.150 Like state licensing laws, these
provisions include requirements regarding
staffing, services and quality assurance
mechanisms.
To be eligible to receive Medicare/Medicaid
reimbursement, most treatments must be
provided by or under the supervision of a
physician.151 State Medicaid programs have the
option of covering addiction treatment under the
Medicaid rehabilitation option, Medicaid clinic
services, targeted case management and
Medicaid managed care waiver programs. The
rehabilitation option is the most flexible for
treatment coverage in that it does not require
services to be medically provided or
supervised.152 The Medicare/Medicaid
Conditions of Participation impose extensive
requirements on participating facilities including
staffing, services and quality assurance
• • t 153
provisions.
* A few states qualified the licensing requirement,
saying that it only applied to certain types of facilities
(e.g., one state noted that the requirement was for
residential treatment facilities only).
' Exemptions appear to apply to programs that solely
are spiritual or religious in nature.
1 In addition, under the Government Performance
Results Act (GPRA) of 1993, federally-operated
programs or those that receive federal funds for
addiction treatment are required to meet certain
reporting requirements.
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All opioid maintenance therapy facilities are
required by federal law to obtain certification
from the U.S. Department of Health and Human
Services' Substance Abuse and Mental Health
Services Administration (SAMHSA)
demonstrating compliance with established
standards for opioid maintenance therapy
programs.154 It is a pre-requisite of certification
that a program be accredited by an organization
approved by SAMHSA.* 155
Accreditation Requirements
In lieu of or in addition to state licensure,
addiction treatment facilities and programs may
be accredited by a national accreditation
organization. While adopting these standards
largely is voluntary,156 some states grant licenses
to programs that have been accredited,157 such
that the program is deemed to have met the state
licensure requirements because it has been
approved by a national accrediting body.' 158 By
granting "deemed status" licenses to accredited
programs, the state essentially delegates to the
accrediting body its responsibility for ensuring
that the facility or program meets state licensure
requirements.159 Accreditation standards are
more detailed than state licensing requirements
and while some require facilities and programs
to use evidence-based practices or to analyze
patient outcomes,160 not all do. Furthermore,
accreditation standards do not require staff to be
qualified to provide a full range of evidence-
based treatment, and accreditation does not
necessarily ensure that quality care is
delivered.161
The accreditation process entails a review of the
facility's or program's structure and operational
practices and evaluation of the organization's
clinical care processes and outcomes to confirm
that they comply with standards set by the
To be approved by SAMHSA to accredit opioid
maintenance therapy programs, an accrediting
organization must demonstrate how its accreditation
process will ensure that programs meet the standards
described in federal regulations.
' Select examples of states that allow providers to
have deemed status for state license or require
accreditation for Medicaid include: AL, AK, AZ, AR,
CT and DE.
accrediting body. Accreditation generally is
considered a higher standard of oversight than
state licensing, in that it incorporates "ideal or
optimum" standards rather than minimum
standards, and focuses on continuous quality
improvement.163
A 2007 study of the association between
accreditation and nine indicators of quality care
(categorized as staff-to-patient ratio, treatment
comprehensiveness and treatment sufficiency) in
566 outpatient addiction treatment programs
found only several correlations between
accreditation and quality of care measures.164
Another study that examined the adoption of
evidence-based dosing practices in methadone
maintenance programs found that voluntary
accreditation was strongly related to adoption of
these practices; however, after accreditation
became mandatory in 2000, this relationship
disappeared. The authors speculated that
programs that voluntarily seek accreditation tend
to be resource-rich (in funds, staff and training)
and more motivated to improve their quality of
care, and therefore more likely to adopt
evidence-based practices.165
The five organizations that accredit addiction
treatment programs and facilities in the United
States are:
• The Commission on Accreditation of
Rehabilitation Facilities ( CARF). CARF is
an independent, nonprofit organization that
offers accreditation for addiction treatment
programs and facilities and integrated
addiction/mental health treatment programs
and facilities; it is the largest accreditor of
addiction treatment programs and
facilities.166 CARF accreditation is widely
accepted by state licensing agencies toward
the fulfillment of licensing requirements for
addiction treatment programs and
facilities.167
• The Joint Commission on Accreditation of
Healthcare Organizations (Joint
Commission). The Joint Commission is the
largest accreditor of all health care services
in the U.S.168 and the second largest
accreditor of addiction treatment programs
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and facilities.169 Joint Commission
accreditation is widely accepted by state
licensing agencies toward the fulfillment of
licensing requirements for addiction
treatment programs and facilities.170
• The Council on Accreditation (CO A). COA
is an international accrediting organization.
Originally known for accrediting family and
children services agencies, COA currently
accredits numerous services, including
addiction treatment.171 COA accreditation is
accepted by fewer states (approximately 1 0)
relative to accreditation by CARF or the
Joint Commission.172
• The National Committee for Quality
Assurance (NCQA). NCQA is a nonprofit
health care quality improvement
organization that accredits health care
organizations.173 As of 2005,* Florida and
Michigan were the only states that accepted
NCQA accreditation as fulfilling licensing
requirements for addiction treatment
programs and facilities.174
• The National Commission on Correctional
Health Care (NCCHC). The NCCHC is the
only organization authorized by the federal
government to accredit opioid maintenance
therapy programs that specialize in
correctional settings.175
Of the 13,339 addiction treatment programs and
facilities voluntarily responding to a national
survey
.t
56.9 percent (7,595 facilities) are not
accredited by CARF, the Joint Commission,
COA or NCQA;
21.8 percent (2,909 facilities) are accredited
by CARF;
19.2 percent (2,556 facilities) are accredited
by the Joint Commission;
5.0 percent (664 facilities) are accredited by
COA; and
2.8 percent (371 facilities) are accredited by
NCQA.
176
Professional Staffing Requirements
In licensing standards for medical facilities,
physicians generally are responsible for patient
care.* 177 In contrast, addiction treatment may be
provided not only by people who lack medical
training, but by individuals with no license and
no graduate education or clinical training at
all.178
State licensing laws, federal requirements and
accreditation standards regarding which
professionals may provide and supervise
addiction treatment services in facilities and
programs vary significantly. While some states
require addiction treatment programs to have a
medical director who is an M.D. on staff, others
impose minimum education/training
requirements on directors, supervisors and staff.
Accreditation standards do not recognize
addiction treatment generally as requiring
medical care; rather, they only require physician
oversight for certain services, deferring to states
with regard to which professionals are qualified
to provide addiction treatment. Similarly,
federal requirements stipulate that some types of
care must be provided under the supervision of a
physician, while services such as "rehabilitation
services" do not require supervision by a
physician.179
State Staffing Requirements. In licensing
regulations for addiction treatment facilities and
programs, states typically specify:
The most recent data available. More states may
currently accept the accreditation.
1 The National Survey of Substance Abuse Treatment
Services (N-SSATS). Accreditation by the NCCHC
was not measured in the survey. The categories are
not mutually exclusive, as programs and facilities
may have multiple accreditations.
1 Dentists and other health professionals may be
responsible for services they are qualified to perform
or supervise.
-191-
• A wide range of "qualified providers" (e.g.,
addiction counselors, social workers, nurses)
who may offer and/or supervise treatments-
most of whom are not qualified to provide
medical care or are not trained in addiction;
• The total proportion of patient care that must
be provided by "qualified providers"; and
• The ratio of staff to patients.180
Although state licensing requirements allow an
array of practitioners to provide addiction
treatment, the licensing requirements for
addiction treatment facilities and programs
typically state that "medical services" must be
provided or supervised by a physician; however,
medical services are defined as detoxification,
opioid replacement therapy or the assessment,
diagnosis and treatment of co-occurring medical
or mental health conditions, not as addiction
treatment itself.181
According to CASA Columbia's review, 43
states require non-hospital-based1 outpatient and
residential addiction treatment programs to
employ (at least part time) a physician to serve
either as medical director or on staff; however,
this requirement applies primarily to programs
that provide opioid maintenance therapy which,
by federal regulation, must be supervised by a
physician.182 Few states require non-hospital-
based programs that do not provide opioid
maintenance therapy to have a physician serving
as medical director or on staff; 1 0 states require
residential treatment programs to have a
physician either as a medical director or on staff
and eight states require the same of outpatient
treatment programs. Without a physician as
medical director or on staff, addiction treatment
programs cannot provide a full range of
evidence-based treatment services including
Qualified providers are those who, under state law,
may provide addiction treatment.
' See section on Licensing and Credentialing
Requirements for Individuals who Provide Addiction
Treatment, above.
* Hospital licensing requirements require physician
supervision of patient care; however, the majority of
addiction services offered are not hospital based.
pharmaceutical therapy and treatment of co-
occurring health conditions.
Consistent with these requirements, addiction
treatment services typically are not required to
be supervised by a physician, other than for the
provision of narrowly-defined "medical
services." While states may require that
addiction services be overseen by a clinical or
program director, that position is not required to
be filled by a physician.
Approximately two-thirds of states in CASA
Columbia's review specify that residential
treatment programs (3 1 states) and outpatient
treatment programs (29 states) must have a
program or clinical director. Among the 2 1
states that specify the minimum educational/
training requirements for this position, few have
particularly high standards:
• Eight states require a minimum of a master's
degree;
• Six states require the director to be a
licensed or certified addiction counselor;
• Four states require a minimum number of
years of experience;5
• One state requires a bachelor's degree;
• One state requires an associate's degree; and
• One state simply requires the person to
demonstrate competence to perform certain
services.
A national survey of treatment professionals
conducted in 1998 found that 60.6 percent of
individuals who were responsible for
supervising clinical services in addiction
treatment facilities had graduate degrees and
77.5 percent of these supervisors were certified
or licensed as addiction/mental health
professionals. Among facility directors, 64.0
had a graduate degree and 68.9 percent were
s AZ additionally specifies that the individual must
have a high school diploma or GED.
-192-
certified or licensed as addiction/mental health
professionals.183
CAS A Columbia's survey of directors* of
addiction treatment programs in New York State
found that 67.5 percent had a graduate degree,
16.9 percent had a bachelor's degree, 14.5
percent had some college or an associate's
degree and 1 .2 percent had only a high school or
GED degree.184
Although state licensing laws sometimes dictate
that clinical supervisors, such as program or
medical directors, have special training
(including certification) or experience in
addiction treatment,185 they generally allow
facilities more flexibility to determine the
necessary qualifications, including level of
experience, education or training, as well as the
composition of other clinical staff186
Federal Staffing Requirements. In states that
provide addiction treatment using Medicaid
funding, hospital and clinic services must be
provided under the direction of a physician,187
but if states choose to provide services under the
optional benefits category of rehabilitative care,
they are exempt from this requirement.188 If
services are required to be provided under the
direction of a physician, the facility physician is
not required to be on staff full time, but must be
present for sufficient time to provide medical
direction, care and consultation in accordance
with accepted principles of medical practice.
The facility and the staff providing care also are
required to hold appropriate state licenses,
certifications or registrations.189
The federal regulations for opioid maintenance
therapy programs specify that each program
must employ a medical director and that all
providers, including addiction counselors,
comply with the credentialing requirements of
their respective profession.190
Some of the program directors also may have
served as clinical supervisors, but the survey did not
distinguish between the two roles.
Accreditation Requirements Regarding
Staffing.1 CARF standards require that
programs that offer detoxification, inpatient
care, partial hospitalization, residential treatment
serving "persons with medical needs" or opioid
maintenance therapy have a medical director
who is a physician. Organizations that seek
elective accreditation for assertive community
treatment (ACT)* services must have a physician
on staff. Other services do not require physician
supervision. 191
While CARF requires staff to be licensed or
certified by a credentialing body that uses a
competency-based process,5 it leaves the
determination of which practitioners are
qualified to provide addiction treatment to state
laws and professional associations, thus
allowing for great variation in education and
192
training requirements.
The Joint Commission allows programs to
define the qualifications required for staff to
perform their job and requires staff who provide
care to be licensed, certified or registered "in
accordance with the law." Only opioid
maintenance therapy programs must have a
physician on staff; this person must have
experience in addiction medicine, including
medication-assisted treatment.193
Treatment Service Requirements
Licensed health care facilities must deliver care
that meets standards of medical practice; state
regulations tend to defer to health care
providers— for whom there are well-delineated
standards of education and training in health
care practice— to determine appropriate medical
practice (e.g., which services to provide and how
to provide them).194 In contrast, those who
provide addiction treatment often have minimal
' CASA Columbia reviewed the standards of the two
largest accreditors of addiction treatment programs—
CARF and the Joint Commission.
* As described in Chapter VI, ACT is a treatment
approach for patients with co-occurring addiction and
mental health conditions.
§ Focused on the ability to demonstrate adequate
skills, knowledge and capacity to perform a specific
set of job functions.
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education or training in addiction science, and
there are no accepted standards of practice that
apply across facilities and programs.195
While most states regulate addiction treatment
services, they treat these services as completely
separate and distinct from medical care,* 196 and
state regulations regarding addiction treatment
service requirements vary considerably and tend
to be vague. Accreditors specify required
services in greater detail than state licensing
regulations, as do the federal requirements for
facilities providing opioid maintenance therapy.
State Services Requirements. According to
CASA Columbia's review, the majority of states
regulate the content of addiction services by
requiring adherence to specific guidelines, but
the extent of the regulation varies considerably.1
In addition to listing the types of required
services, the frequency and timing of services
are specified in some cases; for example,
patients receiving detoxification must receive a
psychosocial assessment within 72 hours of
admission197 or patients in intensive outpatient
programs must receive individual or group
therapy for a minimum of six hours over at least
two days a week.198
More than 30 states require addiction treatment
programs and facilities to utilize the American
Society of Addiction Medicine (ASAM) patient
placement criteria, which guide providers in
matching patient needs to specific treatment
services and determining the appropriate level of
care for patients.199
State regulations related to addiction treatment
services tend to specify the categories of
services that addiction facilities and programs
must offer— such as individual, family and group
Except for opioid maintenance therapy and some
detoxification services, which are considered medical
care and must be supervised by a physician.
' Regulations were considered to provide detailed
guidelines if they included, for example, specific
pharmaceutical dosing schedules or specific
assessment criteria (e.g., including onset/duration of
problems, previous interventions/outcomes, health
history/current medical care needs and daily living
skills).
counseling; alcohol and other drug education;
activity therapy and social services200~but are
not particularly specific in requiring that the
services follow evidence-based practices. A
survey conducted in 2006 found that three
states— Oregon, North Carolina and Alaska-
have enacted legislation that mandate or
encourage the use of evidence-based practices in
addiction treatment programs; only Oregon
mandates programs to implement evidence-
based practices under penalty of fiscal
sanctions.201 However, the reach of the Oregon
law is limited to programs and facilities that are
funded by the state.1 202
Federal Services Requirements. The federal
regulations for opioid maintenance therapy
programs include specific admission criteria,
services and procedures for patient care.
Admission is limited to patients who meet
clinical diagnostic criteria for opioid
dependence1* and the person must currently have
addiction and must have become addicted within
one year before treatment admission. A
physician must perform a full medical
examination before admission. Opioid
maintenance therapy programs must provide
medical care, addiction counseling, vocational
and educational services and other assessment
and treatment services. The regulations stipulate
that random testing for addictive drugs must be
performed on all patients periodically; ' ' that
treatment medication dosing must be calculated
by a physician familiar with the "most up-to-
date" labeling; and that for patients receiving
1 The Department of Corrections, the Oregon Youth
Authority, the State Commission on Children and
Families and the part of the Oregon Health Authority
that deals with mental health and addiction issues.
§ Determined using accepted clinical criteria, such as
those in the DSM-IV.
** The one -year requirement may be waived for
persons released from penal institutions (within six
months after release), pregnant women (a program
physician must certify pregnancy) or previously-
treated patients (up to two years after discharge).
tt All patients are to be drug tested initially and then
eight times per year for patients in maintenance
treatment and monthly for persons receiving long-
term detoxification treatment.
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methadone, the initial dose cannot exceed 30
milligrams.203
Accreditation Service Requirements.
Accreditation organizations delineate detailed
specifications related to addiction services
provided by facilities and programs.
CARF requires that addiction services be
evidence based, explicitly stating that care
should incorporate "current research, evidence-
based practice, peer-reviewed scientific and
health publications, clinical practice guidelines
and/or expert professional consensus." The
facility must have written policies regarding
service delivery including screening, referrals,
medication use and control, discharge and
follow up. 204 CARF sets forth procedural
requirements for the above services, as well as
orientation, assessment and the development of
"person-centered plans" for treatment. ' CARF
offers accreditation standards for each of the
"core program areas" that programs and
facilities may elect to have accredited, such as
assertive community treatment (ACT),
community integration,1 detoxification, day
treatment, drug court treatment, partial
hospitalization and inpatient services. Standards
for the core program areas are very detailed and
cover which services must be provided, by
whom and how often. § 205
The process of physically controlling, transporting,
storing and disposing of medications, including those
that are self-administered by patients.
' Treatment plans developed with the input of
patients regarding their goals, needs, strengths,
abilities, preferences, desired outcomes and cultural
background.
* A form of treatment that provides opportunities for
community participation as a means of optimizing
personal, social and vocational competency in order
to live successfully in a community.
§ For example, day treatment must be provided at
least three hours a day, four days a week; must
include three interventions from a designated list of
interventions (e.g., family therapy, group counseling,
individual psychotherapy, occupational therapy,
alcohol and other education) plus two additional
activities (nutritional/fitness/leisure/social); the
program must be directed by a qualified behavioral
health practitioner (a person certified, licensed,
registered or credentialed by a governmental entity or
The Joint Commission requires facilities to have
written procedures for eligibility for admission
and for most services. The standards for
addiction treatment programs include procedural
requirements governing essential services such
as screening and assessments; medical
history/physical examinations; screening for
physical pain, nutritional status and signs of
trauma/abuse/neglect/exploitation; special
provisions for services provided to vulnerable
populations (children, individuals with
intellectual/developmental disabilities); care that
reflects patients' needs, preferences and goals;
coordination of care; necessary referrals;
primary physical care; and discharge/transfer
that assures continuity of care.206 The standards
do not specify what kind of psychosocial or
pharmaceutical services should be provided,
leaving much room for variability in the quality
of patient care.
Because opioid maintenance therapy is
considered "medical care," Joint Commission
standards for opioid maintenance therapy
programs are more numerous and detailed. For
example, such programs must address relapse
prevention in discharge planning; use DSM-IV
or other accepted clinical criteria to diagnose
addiction; perform an initial toxicology test and
a comprehensive screening of patients' medical
conditions; document current chronic or acute
medical conditions; provide hepatitis A and B
immunizations; manage current misuse of other
drugs that are not the primary focus of
treatment; and include smoking cessation as an
integral component of care.207
Quality Assurance Requirements
Quality assurance requirements can be imposed
by state and federal governments, by accreditors
or by payers. Such requirements focus on
assuring specific organizational structures,
a professional association as meeting the
requirements necessary to provide mental health or
alcohol and other drug services); screening and
assessments must be provided; and when psychiatric
services are necessary, a psychiatrist must be
available 24-hours a day.
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processes and outcomes as ways of assuring
quality.208
Accreditation of health care facilities tends to
focus on structural measures (e.g., physical plant
adequacy, nursing ratios, certification of
providers, availability of certain services).
While patient outcomes (e.g., survival, function,
quality of life) are in many ways the most
important variables, they are difficult to collect
and analyze. Patient outcomes may be affected
by factors independent of the quality of a
specific health care service delivered, including
co-occurring conditions, patient compliance and
lifestyle. Outcome data also are subjective and
vary according to the setting and the particular
instruments used to measure them. Given these
barriers, quality assurance efforts tend to focus
on the process of care, which examines the
frequency with which interventions known to
correlate with positive outcomes are
performed.209
State Quality Assurance Requirements. State
quality assurance requirements for addiction
treatment programs and facilities are highly
variable and focus mainly on process. For
example, a program that is run efficiently and
maintains good records would be considered a
quality program regardless of patient outcomes.
CASA Columbia's state-by-state analysis of
regulations and statutes found that 45 states have
some type of quality assurance requirements for
addiction treatment facilities and programs,
although this may take the form of simply
requiring the establishment of a quality
improvement plan. Fewer than half of these
states (2 1 states) have explicit requirements that
patient outcome data be collected but, even for
those that do, the types of data required rarely
are specified. Four of the states that require the
collection of patient outcome data have
explicitly-defined categories of such data, but
these categories focus primarily on reductions in
specific types of substance use or its
consequences-such as reduction or elimination
of the use of illicit drugs, reduction or
elimination of associated criminal activities or
improvement of quality of life. The absence of
other indicators linked to improved health and
function or effective disease management is
noticeably absent.
CASA Columbia's review found little evidence
that states impose sanctions on facilities that fail
to meet the outcome reporting requirements and,
for those that do, the penalties are minor (e.g., a
$100 fine).
Federal Quality Assurance Requirements.
Federal quality assurance requirements vary by
program. Federal Medicare/Medicaid conditions
of participation address quality assurance issues
by requiring utilization review committees to
assure compliance with written procedures for
evaluating admissions, continued care and
discharges; linking treatment plans to
established goals; clinical record keeping; and
requiring that the group of professionals within
the program or facility that develops patient care
policies review and act upon recommendations
from the utilization review committee.210
The federal regulations for opioid maintenance
therapy programs require continual quality
assurance measures which must include ongoing
assessment of patient outcomes (not specified)
and annual review of program policies and
procedures.211
All federal agencies that operate programs or
provide funds related to addiction treatment are
required to report on the performance of those
programs in accordance with the Government
Performance Results Act (GPRA) of 1993. In
order to fulfill their requirements under the Act,
each federal agency must develop a strategic
plan (including annual performance targets)
covering each of their programs, conduct
evaluations to assess how well a program is
working and why particular outcomes have (or
have not) been achieved and produce program
performance reports based on analyses of
program effectiveness.212
SAMHSA is the leading federal agency that
funds addiction treatment; it administers the
Substance Abuse Prevention and Treatment
Block Grant (SAPTBG), a federal grant that
funds state prevention, treatment, recovery
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supports and other services. SAPTBG is a
major source of funding for state-run or state-
funded treatment programs.214 SAMHSA's
performance targets and outcome measures for
this program include required data collection
and reporting on the number of admissions to
treatment programs receiving public funding and
on outcomes, including abstinence^
employment, school enrollment, justice system
involvement and housing.215
Accreditation Requirements for Quality
Assurance. CARF requires addiction treatment
facilities and programs to conduct a records
review to assess the quality and appropriateness
of services provided, as well as a review of the
patterns of service utilization. Programs must
analyze patient outcomes— including abstinence;
reduction in relapse, criminal activity and
hospitalizations; improved psychological
function; housing situation; employment status—
to determine the effectiveness of services.216
Joint Commission standards for addiction
treatment facilities and programs focus more on
performance improvement measures by
requiring programs to conduct data collection
and data analysis and to identify any
opportunities for improving performance (e.g.,
in reducing errors, incorporating patient goals or
comparison with external quality measures).
Only opioid maintenance therapy programs are
required specifically to collect outcome data,
which include measures of the use of illicit
opioids, criminal involvement, health status,
retention in treatment and abstinence.217
States that receive SAPTBG funds must, among
other things: spend five percent of the funds on
increasing treatment capacity for pregnant women
and women with dependent children by establishing
new programs or expanding the capacity of existing
programs, improve the process for referring
individuals to treatment facilities that can provide the
most appropriate treatment modality, and make
continuing education available to employees of
funded facilities.
' Measures of client abstinence reflect no past-month
use of alcohol or other drugs at discharge. Discharge
is defined as the date of last service.
-198-
Chapter X
The Evidence-Practice Gap
The prevention and reduction of the risky use of
addictive substances and the treatment of
addiction, in practice, bear little resemblance to
the significant body of evidence-based practices
that have been developed and tested;* indeed
only a small fraction of individuals receive
interventions or treatment consistent with
scientific knowledge about what works.1
Providing quality care to identify and reduce
risky use and diagnose, treat and manage
addiction requires a critical shift to science-
based interventions and treatment by medical
professionals— both primary care providers and
specialists.
Significant barriers stand in the way of making
this critical shift, including an addiction
treatment workforce that is largely unqualified
to implement evidence-based practices; a health
professional that should be responsible for
providing addiction screening, interventions,
treatment and management but does not
implement evidence-based addiction care
practices; inadequate oversight and quality
assurance of treatment providers and
intervention practices; limited advances in the
development of pharmaceutical treatments; and
a lack of adequate insurance coverage.
Recent efforts by government agencies and
professional associations have begun to tackle
these challenges to closing the evidence-practice
gap, but are insufficient.
Current Approaches to Risky
Substance Use and Addiction Are
Inconsistent with the Science and
with Evidence-Based Care
Unlike other public health problems and
diseases that are met with qualified medical care
See Chapters IV- VI.
-199-
and cutting-edge interventions, the reigning
paradigm in the health community for
addressing risky substance use and addiction is
to fail to address the problem directly. Instead,
risky users of addictive substances are in most
cases sanctioned in terms of the consequences
that result— such as accidents, crimes, domestic
violence, child neglect or abuse-while effective
interventions to reduce risky use rarely are
provided. Those with addiction frequently are
referred to support services, often provided by
similarly-diagnosed peers who struggle with
limited resources and no medical training, to
assist them in abstaining from using addictive
substances. While social support approaches are
helpful and even lifesaving to many-and can be
important supplements to medically-supervised,
evidence-based interventions— they do not
qualify as treatment for a medical disease.
In short, the gap between the evidence regarding
what works in interventions for risky substance
use and in the treatment and management of
addiction versus on-the-ground practice is wide,
and nothing short of a significant overhaul in
current approaches is required to bring practice
in line with the evidence and with the standard
of care for other public health and medical
conditions.
While a wide range of trained health
professionals can screen for risky use of
addictive substances and provide brief
interventions, physicians should be essential
providers of the full range of addiction treatment
services. They should provide this care in
collaboration with multiple medical specialties
and sub-specialties and a multi-disciplinary team
of health professionals, including physician
assistants, nurses and nurse practitioners and
graduate-level clinical mental health
professionals (psychologists, social workers,
counselors).
Given the prevalence of addiction in society and
the extensive evidence regarding how to
identify, intervene and treat it, continued failure
to do so signals widespread system failure in
health care service delivery, financing,
professional education and quality assurance. It
also raises the question of whether the low levels
of care that addiction patients usually do receive
constitutes a form of medical malpractice.
Patient Education, Screening, Brief
Interventions and Treatment Referrals
Despite the documented benefits of screening
and early intervention practices, medical and
other health professionals' considerable
potential to influence patients' substance use
decisions, and the long list of professional health
organizations that endorse the use of such
activities, most health professionals do not
educate their patients about the dangers of risky
substance use or the disease of addiction, screen
for risky substance use, conduct brief
interventions when indicated, treat the condition
or refer their patients to specialty care if
needed.2
Since the 1950s, screening has been considered
an important element of general health care and
as early as 1968, the World Health Organization
(WHO) laid out the principles of early disease
detection.3 Based on those principles, risky
substance use and signs of addiction are highly
conducive to screening by general health
practitioners: they are significant health
problems with well-understood natural histories,
there are non-invasive tests and easily-detected
symptoms and early interventions result in
favorable outcomes.4 Unfortunately, there is a
considerable gap between what current science
suggests constitutes risky substance use and the
thresholds set in some of the most common
screening instruments for determining that an
individual meets criteria for risky substance use
and is in need of intervention (see Chapter IV).
Medical and other health professionals are in
ideal positions to educate patients, conduct
screening and brief interventions and refer
patients to treatment. The vast majority of
adults (82.2 percent) and children (92.1 percent)
had regular contact with a health professional in
20 10.5 There are many venues where health
professionals can conduct patient education,
screening and brief interventions with relative
ease and most patients would be receptive to
See Chapter IV.
-200-
these practices.6 These include primary care
medical offices, dental offices, pharmacies,
school-based health clinics, mental health
centers and clinics, emergency departments and
trauma centers, hospitals or encounters with the
justice system due to substance-involved
crimes.7
Yet, there is no evidence to suggest that medical
and other health professionals routinely avail
themselves of these opportunities.8 To the
contrary, a 2000 CASA Columbia survey found
that only 32.1 percent of physicians regularly do
even one of the following: administer a health
history form to patients at least annually with
one or more substance use questions; administer
a screening instrument to detect the risky use of
one or more substances; discuss substance use
with pregnant patients; or "almost always" ask
patients about their substance use when they
suspect a patient has a problem.9
The consequences of failure to identify risky use
or detect signs of addiction can be life
threatening. Mistaking symptoms of risky
substance use for signs of other conditions may
lead to a misdiagnosis or to prescribing
medications that are unnecessary, produce
dangerous drug interactions, compound an
existing addiction problem* or create additional
health risks. 1 1
Thirty percent of patient respondents in CASA
Columbia's 2000 survey of physicians and patients
said their physician knew about their addiction and
still prescribed psychoactive drugs such as sedatives
or Valium.
This gap between evidence and practice is
particularly acute for adolescents because of the
critical importance of prevention and early
intervention in this population. Screening and
intervention services by health professionals for
adolescents rarely is part of routine practice
despite the abundance of guidelines and
recommendations for screening this population;
the knowledge that nearly three out of four high
school students have used tobacco, alcohol or
other drugs; and the availability of effective
interventions.12
Current Practices Related to Tobacco. The
majority (68.8 percent) of adults who are current
smokers report that they want to quit smoking, f
yet less than half (48.3 percent) of smokers who
saw a health professional in the past year
reported receiving advice to quit.1 13 A survey
of 6th" through 12th-grade students found that
64.5 percent reported that in the past year no
medical doctor, dentist or nurse asked them
whether they smoked cigarettes,8 14 even though
screening and interventions by health
professionals can have a substantial impact on
young smokers.15
A large-scale analysis of national data" of
clinical preventive services delivered to
asymptomatic patients in clinical settings
estimates that only 35 percent of the population
receives tobacco screening and brief
interventions in accordance with the
' 52.4 percent of current and former smokers (those
who quit smoking in the past year for six months or
longer) had made a quit attempt that lasted longer
than one day in the past year; however, only 6.2
percent report that they have quit successfully.
* Medicare beneficiaries were the most likely to
receive smoking cessation advice (59.0 percent) and
those without health insurance were the least likely to
receive smoking cessation advice (35.3 percent).
§ CASA Columbia's analysis of data from that survey
found that, of those who smoked, only 21.4 percent
said that these health professionals told them to stop
smoking.
** Including the National Health Interview Survey
(NHIS), the Behavioral Risk Factor Surveillance
System (BRFSS) and the Healthcare Effectiveness
Data and Information Set (HEDIS) performance data.
...Primary care physicians do not routinely
provide any comprehensive screening for
substance use disorders. . . [When they do provide
treatment referrals, however, some encounter]
addiction treatment services as a "black hole ". . .
They are not informed of patient progress,
treatment completion or non-completion or
recommendations for continuing care. This
contrasts significantly with referrals to other
specialists wherein the treatment is regularly
communicated and a collaborative relationship is
maintained. 10
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recommendations of the United States
Preventive Services Task Force (USPSTF).16
Another study found that while physicians knew
of their patients' smoking status at 68 percent of
office visits, they provided smoking cessation
counseling at only 20 percent of visits by
smokers.17 Analysis of national data found that
physicians provided counseling in 22.5 percent
of visits by current adult tobacco users; only 2.4
percent of current tobacco users were prescribed
medications for smoking cessation.* 18 A
national survey of medical professionals-
including primary care physicians, emergency
medicine physicians, psychiatrists, registered
nurses, dentists, dental hygienists and
pharmacists— indicates that whereas most report
asking patients if they smoke and advising those
who smoke to quit, they are much less likely to
follow through with assessments or referrals to a
smoking cessation program.19
A study of physicians in family medicine,
internal medicine, obstetrics/gynecology and
psychiatry found similar results. Although most
(86 percent) report asking patients about their
smoking and advising them to quit, few do much
more than that: only 1 7 percent said they
usually arrange for a follow-up visit to address
the patient's smoking and only 13 percent said
they usually refer patients who smoke to
appropriate treatment.20 One study found that
pulmonologists, cardiologists and family
physicians were the physician specialists most
likely to be familiar with resources regarding
treatment for addiction involving nicotine and
most likely to refer patients to treatment,
whereas psychiatrists, neurologists,
ophthalmologists and surgeons were the least
likely to have such familiarity or to refer
patients.21
A survey of clinical psychologists found that
one-third (32.3 percent) had not thought about
offering smoking cessation counseling to their
patients.22 And although most registered nurses
ask patients about smoking (87.3 percent), only
65.6 percent advise those who smoke to quit and
Both female patients and patients ages 65 and older
were less likely to be prescribed medication.
less than half offer interventions (49.4 percent
provide materials with quitline information and
34.0 percent refer the patient to a smoking
cessation program).23 Another national survey
of nurses' interventions with patients who
smoke found similar results. ' 24
While the U.S. Clinical Practice Guideline on
Treating Tobacco Use and Dependence
encourages dental clinicians to screen their
patients for tobacco use25 and has been
promulgated widely by the United States Public
Health Service and the Agency for Healthcare
Research and Quality, approximately three in 10
dental professionals still do not advise patients
who smoke to quit and approximately three-
quarters do not refer a patient who smokes to a
smoking cessation program.26 This is despite the
fact that many patients expect their dentists to
inquire about their smoking status and to discuss
smoking cessation with them; 30 percent of
dental patients report that they would try to quit
smoking if their dentist suggested they do so.27
Dentists who implement an effective smoking
cessation intervention can expect that up to 10 to
1 5 percent of their patients who smoke will quit
in a given year.28
Pharmacists, as a profession, rarely provide
tobacco cessation counseling; only about seven
percent of patients report being asked by a
pharmacist about tobacco use.29 This is in spite
of the facts that pharmacists are one of the most
accessible groups of health professionals and
they work in settings frequented by smokers and
where tobacco cessation products are available.30
The majority of smokers (83 percent) believe
that pharmacists should be involved in providing
smoking cessation interventions, 73 percent
would join a smoking cessation program offered
at a conveniently-located pharmacy31 and 63
percent who already use nicotine replacement
therapy (NRT) believe that smoking cessation
counseling by pharmacists would increase a
' Seventy-three percent frequently asked patients
about tobacco use and 62 percent advised patients
about quitting. Only 24 percent of nurses
recommended medications to patients for cessation,
22 percent referred patients to cessation resources
and 10 percent recommended use of a quitline.
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smoker's likelihood of being able to quit.32
Something as simple as keeping NRT products
behind the pharmacy counter where customers
would have to ask for them, or within view of
the pharmacist but accessible to customers, is
related to a greater likelihood of pharmacist-
initiated smoking cessation counseling. In one
study, pharmacists who stored NRT products
behind the counter were 4.7 times likelier to
provide counseling ' than pharmacists who stored
the products out of customers' sight; those who
stored them within view but still accessible to
customers were three times likelier to offer
counseling than those who stored them out of
customers' sight.33
Current Practices Related to Alcohol and
Other Drugs. A national survey of patients
who had visited a general medical provider in
the past year found that only 29 percent were
asked about alcohol or other drug use; 9.2
percent were given the suggestion to stop using,
13.6 percent were given a brief intervention and
5.3 percent were referred to counseling. Of
those in the sample who reported having been
asked by a general medical provider about their
alcohol or other drug use and were identified as
risky drinkers, less than half (48.6 percent)
received any type of advice from their doctor
concerning their substance use.34
Another study found that 19.6 percent of
patients who were identified by primary care
practitioners as misusing addictive substances
but who were not diagnosed with addiction did
not receive a recommendation for an active
intervention.35
A national survey of current and former
drinkers, ages 18-39 years, found that 67 percent
saw a physician in the past year but only 49
percent of excessive drinkers1 were asked about
This approach might be less likely to deter
customers from purchasing the NRT products, since
some smokers may be hesitant to ask for assistance.
' To four or more customers per month.
* Those exceeding the National Institute on Alcohol
Abuse and Alcoholism's (NIAAA) guidelines of no
more than four drinks per day or 14 drinks per week
for men and no more than three drinks per day or
seven drinks per week for women.
their drinking and only 2 1 percent of them were
counseled about risky drinking.5 While
respondents ages 18-25 years were most likely
to engage in excessive drinking, they were least
likely to be asked about their alcohol use (34
percent of excessive drinkers ages 1 8 to 25 years
vs. 54 percent of excessive drinkers ages 26 to
39 years).36
Efforts to educate patients and connect them
with needed services also are inadequate in
emergency departments (EDs).37 The American
College of Surgeons Committee on Trauma
designated alcohol and other drug screening as
an "essential diagnostic test" at Level I and
Level II trauma centers,38 yet many trauma
centers do not provide any screening or brief
intervention services for those who may need
them.39 A national survey of ED directors found
that only 1 5 percent reported having formal
screening and intervention policies in their EDs.
While nearly two-thirds (64.5 percent) reported
routinely screening for risky alcohol use via a
serum alcohol level and 23.6 percent reported
using standardized screening instruments, only
nine percent reported offering brief interventions
by trained personnel for risky alcohol use.40
Although the majority of surgeons (89 percent)
say that alcohol is a major burden on their
trauma center (an estimated 40 to 50 percent of
trauma patients have positive blood alcohol
levels) 41 and 76 percent consider other drug use
to be a significant burden,42 trauma center and
ED physicians often fail to address the
underlying alcohol and other drug problems that
cause patients' injuries.43
Despite evidence of the effectiveness of ED-
based screening and brief interventions for
substance-using adolescents,44 a study of
adolescents admitted to hospitals following
trauma injuries in which 15.5 percent screened
positive for alcohol in their blood found that
only 59 percent of those who screened positive
were referred for intervention services.45
14 percent were advised about low-risk drinking
guidelines and seven percent were advised to cut
down.
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Assessment, Stabilization and Acute
Treatment
Despite the existence of effective assessment,
stabilization and treatment options, addiction
treatment today for the most part is not based in
the science of what works.46 Depending on
disease stage and a range of other health and
social factors, some people with addiction may
be able to stop using addictive substances and
manage the disease with support services only;
however, most individuals with the disease
require clinical treatment.47 The failure of many
providers to properly assess the stage and
severity of the disease and provide effective
psychosocial and pharmaceutical therapies
appears in large part to be due to a lack of
appropriate education and training.* 48
While physicians are somewhat better at
assessing tobacco use among their patients and
discussing options for treatment, there is still
much room for improvement. A recent national
survey found that approximately two-thirds of
primary care physicians (68.5 percent) and
psychiatrists (63.8 percent) report discussing
medication options for smoking cessation with
their patients, as do 22.6 percent of dentists and
14.5 percent of emergency medicine
physicians.49
CASA Columbia's 2000 survey of physicians
and patients found that 94 percent of primary
care physicians (excluding pediatricians) failed
to identify addiction as a possible diagnosis
when asked to offer five possible diagnoses of a
patient with symptoms of risky alcohol use.
Most patients responding to that survey (53.7
percent) reported that their primary care
physician did nothing about their addiction; 10.7
percent said their physician knew about it and
still did nothing. The majority of patients (74.1
percent) said their primary care physician was
not involved in their decision to seek treatment
and 16.7 percent said their physician was
involved only "a little."50
CASA Columbia's research also found that 40.8
percent of pediatricians failed to diagnose
See Chapter IX.
addiction when presented with a classic
description of an adolescent patient with
symptoms of addiction involving drugs (other
than nicotine or alcohol).51 However, another
study found that, among adolescent patients
diagnosed with addiction, primary care
physicians recommended some type of follow-
up1 for 94.7 percent of the patients.52 A study of
adolescents admitted to an inpatient psychiatric
unit1 found that one-third met clinical criteria for
addiction, but outpatient clinicians had not
identified addiction in any of these patients
before admission to the inpatient unit.53
Other research found that only 1 3 percent of
patients who received an addiction-related
diagnosis while visiting an ED received follow-
up addiction treatment services within two
weeks of the visit.5 More than 200 patients in
the study had another ED visit within two
months of their initial ED visit,54 suggesting that
hospitals do not appropriately address patients'
addiction or provide them with referrals to
treatment.** 55 A study of ED patients admitted
with cocaine-related chest pain found that three-
quarters (74.7 percent) had not received any
treatment three months after discharge.56
Detoxification Frequently is Considered
Treatment Rather Than a Precursor to
Treatment. A minority of patients who
participate in detoxification programs go on to
receive treatment, despite evidence that
' Defined in this study as any plan beyond periodic
screening, including notification of parents, referral
to counseling, return visit with the primary care
physician or noting that the patient already was in
counseling for substance use.
* Patients were admitted to the unit for psychiatric
conditions other than addiction.
§ The primary diagnosis for patients included in the
study was addiction for 28 percent of the sample,
mental health issues for 13 percent of the sample and
medical (non-psychiatric) disorders for 59 percent of
the sample.
** Another study found that patients with unmet
addiction treatment needs are nearly twice as likely to
be admitted to the hospital and nearly one-and-a-half
times as likely to have made at least one ED visit in
the past year compared to patients without unmet
treatment needs.
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treatment beyond detoxification typically is a
medical necessity.57 In 2008,* only 12.6 percent
of discharges from detoxification programs
transferred to a treatment facility. About one in
10 (10.8 percent) of alcohol detoxification
discharges were transferred to a treatment
facility, as were 20.7 percent of marijuana
detoxification discharges, 13.6 percent of other
illicit drug detoxification discharges,' 18.2
percent of prescription drug detoxification
discharges and 13.9 percent of multiple
substance detoxification discharges.58 Another
study found that only 32.8 percent of Medicaid-
enrolled adult patients discharged from
detoxification received follow-up care within 30
days of discharge.1 59
Addiction Treatment Rarely Addresses
Smoking. Although recent scientific evidence
underscores the unitary nature of the disease of
addiction and the consequent need to address
addiction involving all substances,60 many
addiction treatment providers continue to
address addiction involving alcohol, illicit drugs
and controlled prescription drugs while largely
ignoring addiction involving nicotine.61
Smoking cessation services are not commonly
implemented in addiction treatment settings62 or
in psychiatric treatment settings.63
The reluctance to provide smoking cessation
services to patients in treatment for addiction
involving alcohol or other drugs stems in part
from an unfounded concern that it might
jeopardize patients' ability to abstain from
alcohol or other drug use.64 There is no
evidence that quitting smoking interferes with
Most recent available data.
' 19.4 percent of opioid (other than heroin)
detoxification discharges, 16.4 percent of
cocaine/crack detoxification discharges and 12.4
percent of heroin detoxification discharges
transferred to a treatment facility.
* This disparity stems in part from financial
constraints. Some insurance plans pay only for
medical detoxification but not for addiction treatment
including psychosocial and pharmaceutical therapies.
Some plans that do cover both detoxification and
treatment manage them separately, making continuity
of care difficult.
the effectiveness of treatment for addiction
involving alcohol or other drugs.65 In fact,
research shows improved addiction treatment
outcomes among patients who receive smoking
cessation services, including reduced risk of
relapse following treatment and improved
outcomes for co-occurring addiction involving
alcohol.66 In light of this evidence, some states5
are banning smoking in addiction treatment
facilities and requiring that smoking cessation
services be provided to patients.67 Making
smoking cessation a key component of addiction
treatment programs would go a long way toward
improving treatment outcomes as well as the
long-term health of patients with addiction.68
One study found that fewer than half (43
percent) of addiction treatment programs in the
United States offer formal smoking cessation
services; no data are available on the extent to
which nicotine addiction is fully integrated into
these treatment programs." Among those that
do offer cessation services, more offer
pharmaceutical interventions than psychosocial
interventions (37 percent vs. 18 percent).69
Although rates of smoking among adolescent
addiction treatment patients are high and
effective interventions are available,70 less than
half (42.8 percent) of treatment programs
designed specifically for adolescents offer
smoking cessation services; 13 percent offer a
comprehensive formal program with
pharmaceutical therapy, 15.3 percent offer
counseling only and 14.5 percent offer
pharmaceutical therapy only.71
Less than 20 percent of addiction treatment
providers received any training in smoking-
related issues in the past year.72 This is despite
the fact that the majority (between 65 and 87
percent)'1 of patients in addiction treatment
5 NY, NJ, WA.
CASA Columbia's survey of directors of addiction
treatment programs in New York State found that the
majority (89.2 percent) indicated that treatment for
addiction involving nicotine is offered in their
addiction treatment programs.
' r Data based on a review of several studies.
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programs smoke— a rate more than three times
that in the general population.73
Pharmaceutical Treatments are
Underutilized. A key factor in integrating
addiction treatment into mainstream medicine is
broader implementation of pharmaceutical
interventions, when indicated.74 Yet providers
of addiction treatment vastly underutilize
evidence-based pharmaceutical therapies.75
CAS A Columbia's survey of directors of
addiction treatment programs in New York State
found that less than half (47.0 percent) indicated
that pharmaceutical treatments are offered in
their addiction treatment programs.76
A national longitudinal survey of programs that
offer addiction services* found that the
percentage of programs offering nicotine
replacement therapy (NRT) decreased
significantly from 38.0 percent during 2002-
2004 to 33.8 percent four years later. Programs
were more likely to continue offering NRT if
they were medically oriented (i.e., located in a
hospital setting with access to physicians).77
Underutilization of pharmaceutical treatments is
particularly common in treatment programs that
are publicly funded, small, not located in a
hospital, not accredited' and have few medical
professionals-including physicians and nurses—
on staff78 National data indicate that among
privately- and publicly-funded treatment
programs, approximately half have adopted at
least one pharmaceutical treatment for
addiction.1 79
Including privately-funded treatment organizations,
publicly-funded treatment organizations and
therapeutic communities.
' By the Joint Commission or the Commission on
Accreditation of Rehabilitation Facilities (CARF).
(See Chapter IX for a description of these accrediting
organizations.)
* Approximately 51 percent of privately- funded
programs and 25 percent of publicly-funded
programs adopted buprenorphine in their treatment of
addiction, 40 percent of private programs and 19
percent of public programs adopted acamprosate or
tablet naltrexone, 30 percent of private programs and
16 percent of public programs adopted disulfiram and
The limited adoption of pharmaceutical
treatments for addiction, when indicated, is due
in large part to a lack of qualified medical staff
in addiction treatment programs to prescribe and
monitor medication protocols.80 Thirty-eight
percent of publicly-funded programs do not even
have access to a prescribing physician, nor do 23
percent of privately-funded programs.81
Treatment providers seem to have more negative
attitudes toward the use of pharmaceutical
therapies relative to psychosocial therapies.82
Some treatment programs see pharmaceutical
treatments for addiction, such as the use of
methadone maintenance treatment for addiction
involving opioids, as incompatible with
abstinence-based treatment approaches;83 there
is a stigma among some providers attached to
the use of pharmaceuticals to achieve abstinence
from a drug to which the patient is addicted.
One of the key predictors of the underutilization
of pharmaceutical treatments is adherence of
treatment providers to a strong 12-step ideology
for addiction treatment.84
CASA Columbia's survey of treatment providers
in New York State found that respondents were
more likely to say that recreational therapy/
leisure skills training is a "very important"
intervention for a treatment facility to offer to
patients5 than to say the same of pharmaceutical
** 85
treatments.
Addiction treatment medications also may be
underutilized by physicians themselves due in
part to insufficient evidence regarding optimal
dosages of certain pharmaceutical therapies,
durations of use, how to combine the use of
medications with counseling and the
less than 20 percent of private programs and less than
10 percent of public programs adopted injectable
naltrexone in their treatment protocols.
§ 51.8 percent of program directors, 54.7 percent of
staff providers.
28.0 percent of program directors, 33.8 percent of
staff providers for methadone maintenance treatment
and 43.9 percent of program directors, 45.7 percent
of staff providers for other medication treatments for
addiction such as buprenorphine, disulfiram or
naltrexone.
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generalizability of research-based efficacy
findings to different patient populations.86
Although one study found that each additional
physician on staff in a treatment program was
associated with a doubling of the odds that the
program would adopt the use of pharmaceutical
treatments for addiction,87 having access to a
staff physician does not guarantee access to or
use of pharmaceutical treatments.88 One study
found that 82 percent of publicly-funded
addiction treatment programs with access to a
physician did not prescribe any treatment
medications for addiction involving alcohol; the
same is true of 4 1 percent of privately-funded
treatment programs with access to a prescribing
physician.89
The treatment of addiction involving opioids
presents one of the most glaring examples of the
underutilization of clinically-effective and cost-
effective pharmaceutical treatments for
addiction.91 Buprenorphine is a pharmaceutical
treatment for addiction involving opioids that,
despite a rich body of evidence demonstrating its
efficacy, safety92 and cost effectiveness,93 is
significantly underutilized in practice.94 The
majority (86 percent) of addiction counselors
report not being aware of the effectiveness of
buprenorphine.95
We 're seeing less interest [in prescribing
buprenorphine] than we expected, especially
among primary care physicians.96
-Robert Lubran, MPA
Director
Division of Pharmacological Therapies
Center for Substance Abuse Treatment (CSAT)
SAMHSA
Specific additional obstacles to the widespread
use of buprenorphine by physicians include cost,
lack of insurance coverage and availability
problems due to pharmacies not stocking the
medication.97
Physicians' biases against patients with
addiction may contribute to the limited adoption
of pharmaceutical treatments as well.98 Survey
results from a random sample of internal
medicine, family medicine, psychiatry and pain
management physicians in Maryland found that
only 36 percent of respondents were willing to
prescribe buprenorphine to an established patient
and only 28 percent were willing to prescribe the
medication to a new patient. Seventeen percent
of physicians unwilling to prescribe the
medication said that addiction involving opioids
is best described as a habit rather than an illness;
none of the physicians willing to prescribe the
medication agreed with this statement. Half of
the Maryland doctors who were not willing to
prescribe buprenorphine reported that they
believe that treatment for addiction involving
opioids is beyond the scope of practice of office-
based physicians and 46 percent reported not
wanting patients with addiction involving
opioids in their clinics.99
The reason I am not interested [in prescribing
buprenorphine] is / see this as an opportunity for
drug users who are by class the most lying,
scheming, dishonest group of patients. They need
hard-based, no-nonsense treatment programs. I
can't stand their manipulative behavior.90
Anonymous Physician
The fact that buprenorphine can be prescribed in
physicians' offices for at-home use was heralded
as a step forward in the treatment of addiction
involving opioids. Addiction professionals
anticipated the medication's potential to help
addiction treatment become a more central
component of medical practice.101 However,
these hopes have not come to fruition.102
There is no other comparable example in
medicine where you have evidence-based
treatments that are not available. 100
-Shelly Greenfield, MD, MPH
Chief Academic Officer, McLean Hospital
Professor of Psychiatry,
Harvard Medical School
Director, Clinical and Health Services Research
and Education Division of Alcohol
and Drug Abuse, McLean Hospital
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Nutrition and Exercise Are Not Integrated
into Addiction Treatment. Although good
nutrition and exercise are important components
of comprehensive addiction treatment* 103-
particularly in light of recent research
underscoring common brain circuitry involved
in substance-related addiction and obesity104~the
extent to which nutrition and exercise are
incorporated into addiction treatment has not
been examined. One small study' found that 56
percent of dietitians and nutrition program
managers working in addiction treatment
facilities reported that their facilities offered
nutrition-related addiction education in group
settings to only about half of their patients.
Fifty-six percent of respondents reported
offering nutrition-related addiction education in
individual settings to an average of 1 8 percent of
their patients.105
Formal Treatment Is Conflated with Support
Services. The overwhelming salience and
considerable evidence-although largely
anecdotal-of the benefits of mutual support
programs like Alcoholics Anonymous (AA), for
example, have led many people to conflate such
support services with actual addiction treatment
rather than to recognize them as highly useful
systems of support that should accompany or
follow evidence-based clinical treatment. * 106
Mutual support programs are facilitated by
members whose main credential is that they
themselves have experienced an addictive
disorder and have learned to manage it. Such
support, however, is quite different than
treatment for a medical condition.5 107 Few
would argue that any other disease be treated
See Chapter V.
' Using a non-randomized sample.
* There are some exceptions where, depending on the
severity of disease symptoms and the patient's health
status and degree of social support, certain patients
are able to manage their addiction with support
services only or no interventions at all. In addition, it
should be noted that Twelve-Step Facilitation,
discussed in Chapter V, is a formalization and
professionalization of the 12-step mutual support
model and has been deemed an evidence-based
treatment for addiction.
§ AA openly recognizes addiction as a medical
condition.
solely via support groups composed of those
who themselves have had the condition.
Tailored Treatment Services
Whereas research clearly indicates that to be
effective interventions should be tailored not
only to the stage and severity of a patient's
illness but also to a patient's co-occurring
conditions and other personal characteristics and
life circumstances that might affect treatment
outcome, most health professionals and
addiction treatment programs follow a one- size-
fits-all approach to treatment.
Disease Severity Rarely is Assessed and
Interventions Rarely are Tailored to Stage
and Severity of Disease. It is standard
recommended medical practice to assess the
stage and severity of a patient's disease in order
to develop an effective treatment plan and tailor
treatment accordingly.108 Assessment of disease
severity is an essential part of addiction
treatment as well.109 One of the most widely-
used tools, both in research and clinical practice,
for assessing the severity of addiction is the
Addiction Severity Index, although even this
instrument fails to address addiction involving
nicotine.110 Yet, the extent to which treatment
providers tailor treatment protocols based on the
findings of such assessments is limited.111
Instead, addiction treatment programs typically
utilize a non-tailored approach to patient care.112
Having patients pass through a rigid, time-
limited treatment program that assumes
uniformity in disease symptoms and severity
simply burdens patients with unnecessarily
extensive interventions or with interventions that
are too brief or superficial to have a significant
impact on their symptoms. Yet the standard
treatment for addiction is non-intensive
outpatient treatment,113 often without adequate
professional follow-up care and disease
management. Even residential treatment
typically is limited to a 28-day stay in a program
despite little evidence that the condition remits
after such a brief period of time.114 Given this
standard approach to treatment that focuses
primarily on acute care only, it is little wonder
that relapse is so common and that addiction
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continues to be seen as an intractable condition
largely resistant to treatment.
We are treating these folks with severe and
persistent addiction with a time limited-treatment
of three or four weeks, maybe six or eight, maybe
at the most three months, if you want to include
what's called aftercare. Now, why would we think
that treating a chronic disorder for a few weeks
would lead to improvement 10 years later or five
years later or even a year later? It doesn 't make
any sense.115
-Mark Willenbring, MD
Director, Division of Treatment and Recovery
National Institute on Alcohol
Abuse and Alcoholism
(currently, Associate Professor of Psychiatry,
University of Minnesota)
Interventions Do Not Adequately Address
Co-occurring Conditions. In standard medical
practice, it is recommended that health
professionals assess the presence of co-occurring
conditions in order to develop an effective
treatment plan and tailor treatment
accordingly.116 Although such assessments are
critical in addiction treatment given the very
high rate of co-occurring conditions in people
with addiction, treatment programs frequently
do not address co-occurring health conditions or
do so in a suboptimal way.117
Implementing a one-size-fits-all approach to
treatment based solely on a clinical diagnosis
without consideration of co-occurring health
conditions often amounts to a waste of time and
resources. CASA Columbia's survey of
directors of addiction treatment programs in
New York State found that less than half (48.2
percent) of the program directors indicated that
treatment for co-occurring mental and physical
health disorders is offered in their programs.118
A recent study of patients in residential
treatment for addiction who had co-occurring
mental health conditions underscores the
importance of tailoring treatment to the needs of
the patient population. In this study, those with
co-occurring mental health conditions reported
less satisfaction with treatment, saw fewer
benefits to stopping their substance use, had less
belief in their efforts to control their substance
use to maintain abstinence and were less likely
to employ positive coping skills than patients
with addiction who did not have co-occurring
mental health conditions.119
/ lost my son to addiction and ultimately suicide.
From the time I knew he had a problem until the
day he died, I tried everything at my disposal to
help him get quality care. He went to eight
different programs and they all had a different
approach; many offered conflicting advice.
Only four of them looked at Brian as a whole
person; the other four only looked at his
addiction. Only five included a comprehensive
medical assessment; in fact, only three even had
a full-time doctor on the premises. And
although they each viewed his condition as a
chronic disease requiring effective aftercare and
long term management, none of them had an
effective recommendation for this, nor any
follow up from that program. In a letter to me
during one of his stays in a residential program,
he offered the insight that much of his previous
rounds of treatment had addressed his addiction
in isolation— as if it were unrelated to any
underlying emotional problems. In the last
weeks of his life, Brian was suffering from
severe depression. On the day before he died,
his aftercare program made the decision,
without consulting Brian 's therapist, or his
parents, to terminate their relationship with him.
At the time Brian most needed help, he was left
alone. And so was 1. 120
-Gary Mendell, father
Lost his son Brian, age 25,
to addiction and suicide
Although people with mental illness smoke at
significantly higher rates than the general
population, smoking cessation services rarely
are provided by mental health treatment
professionals.121 Generally psychiatrists are less
likely than family physicians to inquire about
smoking, offer advice on quitting or assess
patients' willingness to quit.122 Yet, because
individuals with severe mental illness interact
with psychiatrists to a greater extent than with
primary care physicians (who typically are the
main referral source or provider of smoking
cessation interventions), patients in mental
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health settings who smoke may be even less
likely to receive the smoking cessation services
they need.123 Psychiatrists may eschew smoking
cessation interventions because they believe
"patients have more immediate problems to
address;" some medical and other health
professionals also may be reluctant to encourage
smoking cessation because they feel it "gives
patients with psychiatric illnesses comfort while
dealing with their mental illness symptoms."124
Contrary to these beliefs, research shows that
smokers with mental health conditions are as
motivated as those in the general population to
quit smoking125 and one study showed that the
majority (79 percent) of mentally ill smokers
want to quit.126
Interventions Rarely are Tailored to Patient
Characteristics that Might Affect Treatment
Outcomes. Not taking into account a patient's
age, gender, race/ethnicity, socioeconomic status
or system of personal supports in designing a
treatment intervention can compromise
otherwise effective treatment plans.
Chapter VI of this report outlines specific
treatment needs of special populations and
Chapter VII shows the gaps in needed treatment
for some of these groups. While the baseline
level of addiction-related services offered to the
general population is inadequate, the deficiency
in tailored services offered to populations with
special treatment needs is even more glaring.127
Chronic Disease Management
For many individuals, addiction manifests as a
chronic disease, requiring disease and symptom
management over the long term.128 In recent
years, there has been growing recognition of the
importance of comprehensive disease
management in the treatment of chronic health
conditions for which there is no known cure,
where relapse episodes are considered an
expected part of the disease course and where
long-term symptom management is considered
routine care. While this approach increasingly
has been adopted for diseases such as
1 29 1 30 131
diabetes, hypertension and asthma,
addiction treatment largely remains stuck in the
acute-care model.132
Patients with addiction, regardless of the stage
and severity of their disease, typically receive a
diagnosis followed by a swift course of
treatment administered by individuals without
any medical training and then minimal to no
follow-up care.133 In contrast to other chronic
diseases, positive results from a short-term
intervention or treatment for addiction are
expected to endure indefinitely and relapse
commonly is viewed as a sign of treatment
failure, at best, and as evidence of a deficit in
patients' willpower or dedication to managing
their condition, at worst, rather than as a result
of inadequate treatment or follow-up care.134
Evidence of the acute care approach to addiction
treatment is that current Medicare and Medicaid
regulations indicate that hospital readmissions
for patients with addiction involving alcohol are
not to be treated as extensions of the original
treatment but rather as a new admission to treat
the same condition. Readmissions can be seen
as evidence that treatment is not working and
typically are not covered unless a physician can
document a change in the patient's physical,
emotional or social condition that makes it
reasonable to expect that additional treatment
would improve the patient's condition, or
documents why the initial treatment was
insufficient.135 Given that addiction often is a
chronic disease and that relapse is possible,
limitations on hospital readmissions may reduce
access to needed care and reflect a fundamental
mischaracterization of the disease and its
expected course of treatment.
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Examples of the Evidence-Practice Gap in Addiction Treatment throughout History
The use of addiction treatments that are not grounded in science has a long history. While most of these approaches have
been discredited with time, some have proven to be prescient in their foreshadowing of current treatment approaches, both
those that are evidence based and those that continue to profit from claims about being able to treat or even cure addiction in
manners that largely are not based on scientific evidence.
For example, in the late 1700s, Dr. Benjamin Rush, the "father of American psychiatry," was the first American doctor to say
that "habitual drunkenness should be regarded not as a bad habit but as a disease"136 that should be treated.137 In the late 19th
century, medically -based addiction treatment mostly involved trying to cure individuals of their addiction, often with the use
of other addictive substances.138
By 1910, private sanitariums in the United States offered specialized treatment for addicted individuals— but only for those
who could afford the expense. Similar to today, many of the "treatment experts" opening facilities were savvy businessmen
or enterprising physicians, including Harvey Kellogg (later of cereal fame) and Dr. Leslie E. Keeley. Between 1892 and
1893, almost 15,000 people with addiction were treated at the famous, yet controversial Keeley Institutes.139 Keeley's
treatment for addiction involved bichloride of gold remedies, a substance purportedly containing gold that would cure
addiction involving alcohol and opioids. The use of bichloride of gold became highly controversial and was opposed by the
American Medical Association (AMA). After the death of Dr. Keeley in 1900, the popularity and ultimately, the existence of
his institutes waned.140
Although Keeley's treatments were later discredited, his position that addiction was decidedly a disease rather than a
religious or moral failing was ahead of its time. His use of "shot treatments" or hypodermic treatments that induced vomiting
was a precursor to later aversion therapies and his introduction of clubs for addicted individuals to receive social support to
maintain sobriety was a precursor to the mutual support programs that remain prominent today. His focus on helping people
quit smoking in the 1920s was prescient in its characterization of nicotine as a harmful and addicting drug.141
Addiction treatment tactics that are based more on the personal charisma of the founders, catchy phrases and simplistic
approaches than on the science of what works in addiction continue to proliferate and show no sign of waning. A simple
Google search produces an abundance of "rehabilitation" approaches and facilities with slogans such as: Learn how to heal
the underlying causes of dependency— and be free of addiction forever!142 A recent study examining treatments that a panel
of experts believes qualifies as quackery in addiction treatment found such treatments as electrical stimulation of the head,
past-life therapy, electric shock therapy, psychedelic medication and neuro-linguistic programming to be "certainly
discredited."143 Nevertheless, unsubstantiated interventions continue to be used to this day, many of which prey upon the
desperation of addicted individuals and their families.
In the late 1930s and early 1940s, many hospitals would not admit patients for the treatment of addiction involving alcohol,
so lay approaches became an important option.144 Alcoholics Anonymous (AA), founded in 1935, was premised on
laypersons addicted to alcohol helping one another overcome their addiction and related problems. 145 While the mutual
support/self-help approach maintained the perspective of addiction as a disease— formalized in the development of the
principles underlying the Minnesota Model in the 1950s— the "rehabilitative model" of treatment was seen as distinct from
"the medical model." Standard medical interventions that normally would be applied to diseases were not a significant part
of the treatment, nor were medical or other health professionals called upon to play key roles in treating the disease.146 This
model remains the dominant approach to addressing addiction in the United States. Yet, its limitations and failure to address
addiction the way other diseases are addressed have led to a call to integrate addiction treatment into mainstream medical
care.
Based on the composite opinions of a panel of 75 experts regarding 65 addiction treatments which they rated on a
continuum from "not at all discredited" to "certainly discredited."
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Barriers to Closing the Evidence-
Practice Gap
America's approach to addressing risky
substance use and providing addiction treatment
has evolved outside of the mainstream public
health and medical systems.* 147 As a result:
• Most primary providers of intervention and
treatment for risky substance use and
addiction do not have the requisite training
or qualifications to implement the existing
range of evidence-based practices and face
many organizational and structural barriers
to providing services;
• Most health professionals do not implement
evidence-based addiction care practices;
• Performance and outcome measures that
should be a routine part of quality assurance
in mainstream medicine are limited and
rarely implemented in addiction treatment;
• The pharmaceutical industry lacks the
incentive to develop new and effective
pharmaceutical interventions for addiction
treatment; and
• Insurance coverage for evidence-based
intervention, treatment and disease
management is inadequate.
Because of the vast chasm between the health
care system and approaches to preventing risky
substance use or treating addiction, medical
professionals fail to address risky substance use
or addiction or take responsibility for
intervention or treatment, risky substance use is
addressed primarily in terms of its consequences
and addiction treatment providers are not held to
the same standards as providers of mainstream
medical care.
See Chapter IX for an in-depth discussion of the
education and training requirements for those
providing services for risky substance use and
addiction.
The lack of integration of screening and
intervention and addiction treatment into
mainstream health care has led to many missed
opportunities to help patients who engage in
risky substance use or who have addiction and
has contributed to the high rates of relapse and
enormous health and social consequences
associated with risky use and addiction.
The Addiction Treatment Workforce is Not
Qualified to Implement Evidence-Based
Practices
For most illnesses, the preponderance of
treatment interventions, including coordination
of services, occurs within mainstream medicine
and is provided and managed by trained medical
professionals. Other highly-trained and
credentialed health professionals may be part of
a team of providers working with a physician.
Motivated and experienced non-professionals
may serve additional vital functions-such as
providing social support to encourage adherence
to a treatment plan and help patients maintain
important lifestyle changes that can reduce the
risk of relapse-but their roles and services do
not supersede or replace those of the medical
team.
In contrast, the majority of care for individuals
with addiction is provided by people without any
medical training at all and rarely is supervised
by medical professionals. Physicians and other
medical professionals typically are absent from
or on the periphery of the treatment process,
occasionally being called in to provide a
prescription or medically monitor a
detoxification protocol.
One of the fundamental barriers to providing
effective treatment is the fact that addiction is
not integrated into medical practice. And a lot
of medical people like and want it that way; they
do not want to deal with addiction; they do not
like to deal with the people and they do not feel
effective addressing the problem. 148
—Keith Humphreys, PhD
Professor
Stanford Medical School
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Addiction treatment services primarily are
provided through community-based treatment
programs that were established in the 1970s and
1980s before the medical model gained support
and changes in the financial structure led to
increasing demands for accountability and
efficiency.149 The treatment provider workforce,
although frequently highly dedicated, is
composed primarily of certified alcoholism and
substance abuse counselors (CASACs)— a
profession for which a college degree typically
is not required and in which counselors receive
limited on-the-job training in evidence-based
practices
150
The result is that much of the current treatment
provider workforce is not equipped to provide
consistent evidence-based treatment, including
administering and monitoring medication
protocols, implementing complex psychosocial
interventions, addressing co-occurring health
conditions or responding to medical
problems that may arise among
individuals undergoing addiction
treatment.151
providers) said substance abuse counselors
(CASACs); 16.3 percent of directors and 17.8
percent of staff providers said social workers,
7.5 percent of directors and 6.7 percent of staff
providers said psychologists and only 1.3
percent of directors and 1.5 percent of staff
providers said physicians.153
Only 9.9 percent of program directors and 13.7
percent of staff providers indicated that a
medical degree is a "very important"
qualification for treatment providers to have; 3.7
percent of directors and 6.5 percent of staff
providers thought that way about a doctoral
degree. A quarter (24. 1 percent of directors and
26. 1 percent of staff providers) felt that a
master's degree was a very important
qualification, and about a quarter (26.8 percent
of directors and 27.3 percent of staff providers)
felt that way about a college/bachelor's
degree.154 (Figure 10.A)
CASA Columbia's survey of addiction
treatment providers in New York State
provides a case in point. It found that
37.2 percent of staff providers do not
have a bachelor's degree' and only
67.5 percent of program directors and
35.0 percent of staff providers have a
graduate degree of any type.152
Further, most treatment providers see
the current state of affairs with regard
to the staffing of treatment programs as
reasonable. When asked which type of
professional they think is best qualified to
provide addiction treatment services, nearly
three quarters of respondents to CASA
Columbia's New York survey (71.3 percent
program directors and 72.6 percent of staff
Figure 10.A
New York State Addiction Treatment Providers' Beliefs
about the Importance of the Following Provider
Educational Qualifications*
26.8 27.3
24.1
26.1
9.9
13.7
3.7
6.5
• Director
i Staff
College/Bachelor's Master's Degree Medical Degree Doctoral Degree
Degree
* Among those who responded that the educational qualification is "very
important".
Source: Casa Columbia Survey of New York State Addiction Treatment
Providers, 2009.
of
In contrast, the majority of treatment providers
in CASA Columbia's survey (61.4 percent of
program directors and 76.3 percent of staff
providers) thought that personal experience with
addiction is an important qualification for
See Chapter IX for specific credentialing
requirements.
29.9 percent had some college or an associate's
degree, 6.6 percent had only a high school degree or
GED and 0.7 percent did not complete high school or
have a GED.
-213-
addiction treatment providers to have.
CAS A Columbia's survey also found that only
11.3 percent of program directors and 8.1
percent of staff providers believe that the
addiction treatment system "should be integrated
into the medical system such that addiction is
treated as a health condition by health care
professionals." Two-thirds of directors (66.3
percent) and 60.3 percent of staff providers,
however, say that the addiction treatment system
"should be two-tiered with health care
professionals providing psychotherapeutic and
pharmacological interventions and individuals
with histories of addiction (in recovery)
providing recovery support services." Fewer
directors (7.5 percent) but more staff providers
(21.3 percent) indicated that "the system should
revolve around a recovery support model with
self-help/mutual support programs as the main
intervention." Fifteen percent of directors and
10.3 percent of staff providers think that nothing
about the system should change.156
Despite this variability in perceptions regarding
what the treatment system should look like,
there is general agreement that the current
system is riddled with organizational and
structural problems that impede the delivery of
quality care, including inadequate financial
resources, high staff turnover and restricted
professional advancement.157 While limited
education and training of most providers and a
treatment culture largely steeped in the self-help
model stand in the way of adopting new,
science-based practices,158 organizational and
structural problems within the current treatment
system compound these limitations and further
prevent the delivery of evidence-based care.159
CASA Columbia's survey of treatment providers
in New York State found that respondents were
most likely to cite a high volume of paperwork
Among program directors, 28.9 percent said
personal experience is slightly important, 25.3
percent said it is moderately important and 7.2
percent said it is very important. Among staff
providers, 36.0 percent said personal experience is
slightly important, 21.6 percent said it is moderately
important and 18.7 percent said it is very important.
(reporting requirements that take up too much
time and resources), insufficient salaries to
attract and retain high-quality staff, insufficient
program funding and insufficient insurance
coverage for patients as barriers that "very
much" stand in the way of providers' ability to
provide effective services to people in need of
addiction treatment— reflecting both frustration
with organizational barriers to quality care and a
non-medical approach to treatment. An
insufficient number of trained medical-level
(MD/DO) professionals was least likely to be
named by providers as a barrier that "very
much" stands in the way of providing effective
treatment services.160 (Table 10.1)
Table 10.1
New York State Addiction Treatment Providers' Opinions
of Barriers that "Very Much" Stand in the Way of
Providing Effective Addiction Services
Program
Staff
Directors
Providers
High volume of paperwork/reporting
requirements
76.8
72.7
Insufficient salaries to attract and retain
74.7
69.8
high-quality staff
Insufficient program funding
62.2
63.3
Insufficient insurance coverage
60.2
61.6
Insufficient number of appropriately trained
staff with the qualifications necessary to
provide treatment for co-morbid conditions
56.1
37.4
Insufficient number of trained master's-
28.0
20.9
level professionals
Insufficient number of appropriately trained
staff with the qualifications necessary to
provide pharmacological therapies
26.5
19.7
Limited motivation among staff members to
be knowledgeable about evidence-based
24.1
19.7
best practices
Insufficient professional standards related
to knowledge and clinical skills for
20.5
21.7
individuals providing addiction treatment
Insufficient federal- or state-level education
and training requirements for individuals
18.1
23.2
providing addiction treatment
Insufficient access to information about
13.3
15.9
best practices
Insufficient number of trained medical-level
12.3
13.0
(MD/DO) professionals
Source: CASA Columbia Survey of New York State Addiction
Treatment Providers, 2009.
-214-
Most Addiction Treatment Providers Do Not
Adopt Evidence-Based Practices.* Many
addiction treatment providers address addiction
in ways that have not been evaluated or proven
effective. While this is due in part to the
inadequate education and training of treatment
providers in evidence-based practices,161 the
larger issue is the significant mismatch between
the qualifications that are necessary for
implementing many evidence-based practices
and the qualifications that the majority of the
treatment workforce currently possesses.162
Because most treatment providers are not
adequately trained, they are not capable of
performing health assessments, prescribing
pharmaceutical medications, treating co-
occurring health conditions or managing a
chronic disease, each of which is an essential
evidence-based addiction treatment practice.163
Most also are not trained in the scientific method
or clinical research, further impeding their
ability to integrate clinical research findings into
treatment practice.164
Education and awareness about evidence-based
practices, however, are not sufficient to ensure
proper implementation of those practices;165
additional steps are necessary to translate
evidence into practice. Although significant
progress has been made in the past decade in
disseminating knowledge about evidence-based
practices and improving attitudes toward them,
less is known about how well such practices are
implemented in treatment facilities and
166
programs.
One study found that treatment programs that
are most likely to adopt clinical and practice
guidelines, including the use of standardized
assessment tools, are those that offer a broad
range of services-medical services, counseling,
pharmaceutical therapy and support services-
and those that receive funding from managed
care organizations. ' 167
1 Programs with managed care involvement were less
likely to be freestanding facilities and more likely to
be associated with multi-service hospital or medical-
based clinics. They also were more likely to have
staff with advanced degrees and less likely to have
staff in recovery. The authors of this study speculate
that programs with managed care contracts might be
likelier than those without such contracts to be
encouraged to have standardized practices.
Evidence-based practice involves the use of current
evidence in making decisions about patient care.
Evidence-based practices aim to combine the best
available research and clinical judgment while taking
into account patient characteristics and needs.
-215-
We have entered the world of showing providers
what is evidence based. Now we must show
providers how to implement it... We haven't
effectively brought practical research results to
individual providers... so they can use if. 168
—William H. Janes
Former Director
Florida Office of Drug Control
Office of the Governor
Evidence from research findings is not generally
accessible and understandable to providers;
we 're failing miserably at that. 169
-Joseph M. Amico, MDiv
President
National Association of Lesbian and Gay
Addiction Professionals
(now Vice President, and association now called
The Association of Lesbian, Gay, Bisexual,
Transgender Addiction Professionals
and Their Allies)
According to the American Psychological
Association, evidence-based practice is the
integration of the best available research and
clinical expertise within the context of patient
characteristics, culture, values and preferences.
Today we have a few places trying to implement
these practices but with major limitations; few
ever implement the practice the way it was
researched.™
-Stephanie Covington, PhD, LCSW
Co-Director
Center for Gender and Justice
Institute for Relational Development
La Jolla, CA
One study found that support staff*— who make
up 24 percent of the treatment provider
workforce in the National Institute on Drug
Abuse's (NIDA) Clinical Trial Network (CTN)T
and have more direct patient contact than
professional counselors and medical personnel-
showed little enthusiasm for evidence-based
practices; they also were more likely to support
intervention techniques that employ
confrontation and coercion-techniques that
contradict evidence-based practice.171 In
contrast, treatment providers affiliated with CTN
who advocated for the use of new evidence-
based practices tended to be more highly
educated.172
A study of counselors' attitudes toward
evidence-based psychosocial and pharmaceutical
practices4 found that those who had more
specific training in the practices and those who
worked in treatment centers where the particular
practices were used routinely tended to perceive
evidence-based practices as more acceptable for
treating addiction.173 Providers with higher
educational degrees are more likely to be
supportive of evidence-based practices than
those with lower-level degrees.174 In contrast,
providers with a strong 12-step orientation to
treatment tend to perceive evidence-based
practices as less acceptable.175
For many recovering paraprofessional
counselors, their counseling "trump card" is
that their personal experience is exemplary of
177
how recovery works.
Health Professionals do not Implement
Evidence-Based Addiction Care Practices^
Mainstream medical and other health
professionals do not adequately address risky
substance use or the disease of addiction in their
professional practice, in part because they are
not trained to do so.** 176 and in part because
they do not see it as a legitimate element of their
role as health professionals.
Education and training alone, however, is
insufficient to change practice. For example,
while numerous guidelines have been produced
and disseminated by government agencies," 178
professional associations179 and quality
improvement organizations such as the National
Quality Forum (NQF)180 and the Agency for
Healthcare Research and Quality (AHRQ),181 to
help health professionals conduct evidence-
based practices related to risky substance use
and addiction, physicians and other health care
providers commonly fail to adhere to these
clinical practice guidelines.182
A recognized cadre of addiction physician
specialists is essential to help educate and train
other physicians, serve as equal partners in
regular medical practice and provide specialty
183
care.
Efforts also must be made to translate physician
training into practice. A lack of time and
resources make it difficult for physicians to
remain up to date with the latest guidelines and
recommendations, and limited reimbursement
may prevent some physicians from taking the
time to implement practice recommendations.184
Support staff is distinct from counselors, managers
or supervisors and medical personnel.
1 CTN is a partnership between NIDA researchers
and community treatment providers to deliver new
evidence-based treatments to a broader population of
patients and to conduct multi-site clinical trials to
determine the effectiveness of new therapies in
diverse settings.
* Including the use of buprenorphine, methadone,
naltrexone, disulfiram, motivational enhancement
therapy and voucher-based motivational incentives.
§ See Chapter IX for a detailed discussion of the
addiction-related credentialing requirements for
health professionals.
Most of the research related to the training of
health professionals in addiction-related services
focuses on tobacco cessation rather than interventions
for addiction involving alcohol and other drugs.
' ' e.g., The Substance Abuse and Mental Health
Services Administration (SAMHSA) produces the
National Registry of Evidence-Based Programs and
Practices (NREPP), an online searchable database of
evidence-based interventions for mental health and
addiction prevention and treatment.
-216-
These factors, however, are not sufficient to
justify the lack of medical attention to a disease
affecting 1 6 percent of the population.
Physicians. Poor training in the care of patients
with addiction relates to low confidence among
physicians in their ability or competence to treat
such patients, negative attitudes toward patients
with addiction, pessimism about the
effectiveness of treatment and low rates of
implementation of evidence-based practices
related to screening, brief interventions and
treatment.185
Only a small proportion of primary care
physicians feel "very prepared" to detect
particular types of risky use (alcohol- 19.9
percent; illicit drugs- 16.9 percent; prescription
drugs— 30.2 percent), which is in stark contrast
to the much higher percentages of physicians
who report feeling "very prepared" to identify
hypertension (82.8 percent), diabetes (82.3
percent) and depression (44.1 percent).188 A
state-based 2006 survey of primary care
physicians found that the vast majority (88
percent) screen for diabetes in adults with risk
factors such as obesity, hypertension and a
family history of diabetes.189
A 2004 survey showed that less than one third of
certain medical professionals— registered nurses,
dentists, psychiatrists and emergency medicine
physicians— had received training in smoking
cessation.190 Another national study found that
only half of psychiatry residency programs offer
training in tobacco cessation, even though a
state -based survey found that 94 percent of
psychiatry residents would be interested in
receiving available training.192 A study of
fourth-year medical students in New York City
found that the majority (85 percent) did not
know of local smoking cessation programs to
which to refer patients.193 And a national survey
of directors and assistant directors of U.S.
medical school obstetrics/gynecology training
programs found that only nine percent reported
offering students at least 1 5 minutes of time
dedicated to improving students' tobacco
cessation skills and only one-third (32.9 percent)
reported that their programs taught students both
how to intervene with patients who smoke and
how to refer them for follow-up.194
Medical curricula, by providing insufficient
information about recent advances in the
neurological science of addiction, perpetuate
misconceptions about the disease of addiction
and inhibit the acceptance of biological models
to explain the disease.195
Inadequate training with regard to tobacco,
alcohol and other drug use also derives from
limited exposure to role models in the field who
have knowledge about these issues.196
Curriculum time and the number of faculty with
expertise in addiction education pale in
comparison to curriculum time and the number
of faculty with expertise in education for health
conditions with similar prevalence rates as
addiction, such as cancer and heart disease.197
More than 20 years ago, the subspecialty of
addiction psychiatry officially was
established,199 yet there often are more addiction
Physicians can be the first line of defense
against risky substance use and addiction, but
they need the right tools and resources}9,6
-Nora D. Volkow, MD
Director
National Institute on Drug Abuse
Most doctors do not look at addiction as part of
their job. They may assess, but they don 't
intervene.1*1
—Brian Hurley
Chair
Physicians-in-training Committee
American Society of Addiction Medicine
As medical students, many of us are perplexed by
the lack of a formal standard of care regarding
addiction. The sad thing is, many of my fellow
students and I feel that too many of our attending
physicians have not demonstrated to us that they
believe that addiction can and should be
addressed and that attitude affects patient care
for the worse.™
— Kimberly Fitzgerald
Fourth-year medical student
-217-
psychiatry residency positions available than
there is demand for them. Although a survey of
psychiatry residents found that most had positive
attitudes towards addiction psychiatry, few
residents believed that addiction psychiatrists
were well paid and less than half (45 percent)
believed a career in addiction psychiatry would
be satisfying.200
The lack of physician training in addiction and
its treatment has very real effects on patient
care. For example, overwhelming evidence has
proven that smoking cessation interventions are
clinically effective and cost effective and that a
patient's chances of quitting smoking are nearly
doubled if a health professional advises him or
her to quit.201 Yet many medical schools do not
require clinical training in smoking cessation.202
Other Health Professionals. Doctoral-level
clinical psychologists are highly trained in
psychosocial therapies, many of which can be
applied effectively to addressing addiction in the
significant proportion of their patient population
that has co-occurring addiction and mental
health disorders.204 Yet because few
psychologists receive adequate training in
screening and intervention for risky substance
users and in diagnosing, treating or referring
patients with addiction, some fail to identify
risky use or addiction or lack confidence in their
ability to provide psychosocial therapies. For
example, one study found that 17.1 percent of
clinical psychologists reported that a barrier to
providing smoking cessation counseling was
their "lack of training in tobacco cessation
skills." Other reported barriers also were related
to a lack of knowledge about the disease: that
smoking was "not the client's presenting
problem" (57. 1 percent); that smoking cessation
is not "a priority for my patients" (28.7 percent);
"it may interfere with therapy goals" (2 1 .2
percent); and "smoking patients are not
interested in smoking cessation counseling"
(19.8 percent).206
Dental professionals also receive inadequate
training in caring for patients with risky
substance use and addiction,207 despite
significant evidence of the important role they
can play in screening, intervention and referral
to treatment.208 There are no national standards
for tobacco cessation education in U.S. dental
schools and the ability to provide tobacco
cessation services is not considered a clinical
competency.209 Only about half of dental
schools and dental hygienist programs* have
tobacco cessation clinical activities integrated in
their student clinics.210 This is despite the fact
that dental professionals are highly receptive to
receiving substance-related training211 and that
appropriate training early in a clinician's career
increases the likelihood that such interventions
will be adopted and implemented in practice.212
Nurses constitute the largest group of health
care professionals213 with extensive patient
contact; therefore, they are ideally situated to
perform patient education, screening and brief
intervention services.214 Yet, nurses are not
adequately prepared to perform these services,
particularly tobacco cessation for which
research indicates they can be particularly
effective.215 Barriers to the implementation of
smoking interventions include a reported lack of
motivation, self- efficacy, institutional support,
time and training.216 Nursing school curricula
have little tobacco control content; there is a
lack of tested curricula, nurse educators are not
Forty-seven percent of dental schools and 55
percent of dental hygienist programs.
There are trained clinicians who do not fully
understand the nature of addiction.
I am amazed at how many if not most medical
professionals have no understanding and little
education on the subject.
My relapse was in part due to ignorance in the
medical profession and lack of medical
addiction understanding during a life-
threatening illness.
...I escaped the clutches of doctors and
psychiatrists with their prescription pads and
rotten advice due to lack of understanding, due
to lack of education.™
-Respondents to CAS A Columbia's
Survey of Individuals in Long-Term Recovery
-218-
trained in it and it is considered to be a low
priority in already overloaded curricula.217
Although pharmacists who engage in tobacco
cessation interventions are effective in providing
those services,218 and despite the important role
pharmacists can play in preventing the misuse of
controlled prescription drugs,219 most are not
well trained to perform these functions, have
little confidence to do so and believe that most
patients are not interested in having them
220
intervene.
A study in California found that the majority of
pharmacists (88 percent) indicated that they
would be interested in receiving specialized
training in tobacco cessation counseling but
fewer than eight percent had received any formal
training.221 A study of pharmacists in Florida
found that 29.2 percent reported that they
received no addiction-related education in
pharmacy school and 53.7 percent reported that
they had never referred a patient to addiction
222
treatment.
Inadequate Use and Development of
Pharmaceutical Treatments for Addiction
The underutilization of pharmaceutical therapies
in addiction treatment is another example of the
disconnect between addiction treatment services
and medical care. Many addiction treatment
providers are unable to prescribe pharmaceutical
therapies and medical professionals who could
prescribe such therapies fail to address
addiction. A related problem is that some
medical professionals appear to have a
disproportionate concern about the safety risks
of addiction medications relative to medications
aimed at treating other medical conditions. For
example, although side effects for some
addiction medications have been noted and
safety concerns raised-particularly with regard
to smoking cessation treatments,223 side effects
exist for many medications aimed at treating
other health conditions and typically are
acknowledged as an acceptable risk of treatment.
Even when utilizing pharmaceutical treatments,
medical professionals often fail to prescribe
them at therapeutic doses. For example,
methadone, which is used in treatment for
addiction involving opioids, often is not
prescribed as clinically recommended,
undermining its effectiveness.224 Specifically,
although it is well understood that dosages
between 60- 1 00 mg per day promote retention in
treatment and reduction of opioid use,225 34
percent of patients are given doses of less than
60 mg per day and 1 7 percent are given doses of
less than 40 mg per day.* 226 Treatment
programs more likely to give suboptimal doses
of methadone include those with directors who
take a 12-step approach to addiction
227
treatment.
Furthermore, despite the potentially vast market
for pharmaceutical treatments for addiction, the
pharmaceutical industry has not made
substantial investments in the development of
new and effective addiction treatment
medications.231 One of the most significant
contributing factors to the increased medical
treatment of mental health disorders, such as
depression and anxiety, in the past two decades
has been the development and marketing of
pharmaceutical treatments for these
conditions.232 However in recent years, the
pharmaceutical industry has cut back
dramatically on investments in the development
of new pharmaceutical therapies for these and
other mental health conditions.233 The large
profits that pharmaceutical companies were able
to accrue from medications that were modified
Although initial methadone treatment begins at
dosages under 40 mg/day, the amount is increased
gradually until cravings disappear.
The Institute of Medicine and the Office of
National Drug Control Policy (ONDCP) have
recommended that treatment for addiction
involving opioids be integrated into mainstream
medical practice to improve availability and
quality.228 New York City has been a leader in
this area with its Methadone Medical
Maintenance program established more than 25
years ago,229 yet only 56 percent of need for
methadone treatment in New York City was met
in 2009;230 inadequate training of providers may
have restricted its expansion and integration
with mainstream medical care.
-219-
versions of drugs already approved by the Food
and Drug Administration meant that investments
in innovative new medications were limited.
Coupled with the rising cost of research and
development, the fact that pharmaceutical
companies face dramatic losses once the patents
on many of their largest money-making drugs
expire makes the current climate for the
development of new innovative medications
quite unfavorable.234
This is particularly unfortunate since recent
advances in addiction science have highlighted
specific neurotransmitter receptors and
transporters that underlie addiction and that are
promising targets for the development of
medications to prevent and treat addiction.235
Aside from economic concerns, other factors
inhibiting investments in new pharmaceutical
interventions for addiction include an
underestimation of the market for addiction
treatment medications (i.e., the size of the
population with addiction), the belief that the
majority of those with addiction lack health
insurance and the ability to pay for medications,
and the long-standing stigma associated with the
use of illegal substances and the disease of
addiction.236
Translating the rapidly-evolving science of
addiction into science-based treatments will
require dramatic changes in incentives for the
pharmaceutical industry to invest in innovative
medications, increased public understanding that
addiction is a treatable disease, and increased
involvement of the health care system in its
prevention and treatment.
Inadequate Quality Assurance
Addiction treatment providers do not speak with
clarity or consistency about what the goals of
treatment are, what counts as quality treatment,
how performance and outcomes should be
measured and what practices should be
implemented to improve treatment and achieve
measurable outcomes.* 239 And because
addiction treatment for the most part is not
integrated into mainstream health care, quality
assurance standards and efforts to improve such
standards in mainstream medicine largely do not
apply to addiction treatment.240 For example,
organizations like the Council on Graduate
Medical Education and the National Advisory
Council on Nurse Education and Practice are
public-private partnerships with Congressional
mandates to provide sustained assessment of the
needs of the medical and nursing fields.241
However, these organizations do not appear to
address addiction treatment and comparable
organizations for addiction treatment do not
exist.
Efforts to assure quality treatment within the
mainstream medical system for patients with
addiction are not typically adhered to. For
example, as far back as 1979, the American
Medical Association (AMA) adopted as policy
the AMA Guidelines for Physician Involvement
in the Care of Sub stance- Abusing Patients,
which states that every physician must assume
clinical responsibility for the diagnosis and
referral of patients with addiction and explicates
the particular competencies needed to fulfill that
responsibility. Other similar efforts followed,
with a national conference sponsored by the
Office of National Drug Control Policy, the
Leadership Conference on Medical Education in
Substance Abuse, in 2004. Despite these and
other efforts by government and professional
organizations to put forth guidelines and
principles aimed at ensuring proper training in
risky substance use and addiction, physicians
continue to be insufficiently equipped to address
the needs of their substance-involved patients.242
See Chapter IX.
For the most part, SUDs [substance use
disorders] have not been high priority targets
for the pharmaceutical industry. Even for
smoking cessation, which offers a huge
potential market, investments are negligible
compared with the costs associated with
developing medications to treat the
237
consequences of smoking.
-Volkow & Skolnick, 2012
-220-
Efforts to assure quality treatment for addiction
have proven highly fallible, with many barriers
standing in the way of adequate performance
and outcome measurement, including limited
consensus regarding core quality standards and
measures, inadequately developed measures and
improvement mechanisms, and inadequate
infrastructure and technical capacity.243
Further, the way in which addiction treatment is
evaluated differs considerably from the
evaluation of the effectiveness of treatment for
other health conditions like diabetes,
hypertension and asthma. Specifically,
evaluations of the effectiveness of treatment of
chronic diseases typically are conducted while
the patient continues to receive treatment, since
the treatment is considered critical to managing
the disease. In the case of chronic addiction,
however, evaluations of treatment effectiveness
usually are conducted after the treatment has
been withdrawn.244 In other words, we use an
acute care model to evaluate treatments for a
chronic condition.
Furthermore, because treatment facilities in
some states cannot be licensed to provide both
mental health and addiction treatment services,
the mental health and addiction treatment
systems are divided further. Given the large
number of patients who suffer from co-occurring
addiction and psychiatric disorders, the inability
to treat both conditions concurrently within the
same program is a significant barrier to
providing quality care; it reduces the diagnosis
and treatment of co-occurring conditions,
impedes coordination of care, and increases the
number of transfers which disrupts treatment.245
Lack of Consensus Regarding the Main Goals
of Treatment. The primary goals of medical
care are the prevention, diagnosis and treatment
of illness, injury and disease, and the consequent
relief of pain and suffering.246 The picture is not
as clear in addiction treatment: there is little
agreement among addiction treatment providers
about what the goals of treatment are or should
be and whether successful treatment is defined
by abstinence, a reduction in clinical symptoms
or a reduction in negative health and social
consequences.247 Goals are not defined as
improving health and function or disease
stabilization as they are with other health
conditions. Such inconsistency in goals makes
measuring and assessing the effectiveness of
treatment very difficult.
CASA Columbia's survey of members of key
treatment provider associations found that the
majority (78.5 percent) "strongly agree" that
improvements in functioning (e.g., employment,
education, parenting, family stability, crime and
recidivism, health, happiness, citizenship) is an
important goal of addiction treatment; about half
(52.5 percent) "strongly agree" that complete
abstinence is an important goal; 44.0 percent
"strongly agree" that remission of clinical
symptoms is an important goal; and 43.8 percent
"strongly agree" that reduced substance use is an
important goal. Nearly half (45.1 percent) of
respondents "strongly agree" that the patient
should be allowed to set the goal that is right for
him or her.248
Respondents to CASA Columbia's survey of
treatment program directors and staff providers
in New York State were more uniform in their
support of complete abstinence as the main
treatment goal for someone with addiction
involving nicotine, alcohol or other drugs.249
(Table 10.2)
See Appendix F.
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Table 10.2
New York State Addiction Treatment
Providers' Opinions of the Main Goal of
Treatment, by Substance
Program
Directors
Staff
Providers
Tobacco
Complete abstinence
49.4
48.2
Reduced use
10.8
21.3
Fewer negative consequences
4.8
11.3
Goal set by patient
41.0
41.1
Other goal
3.6
6.4
Alcohol
Complete abstinence
61.4
70.2
Reduced use
3.6
9.2
Fewer negative consequences
10.8
9.2
Goal set by patient
25.3
22.0
Other goal
2.4
3.5
Other Drugs
Complete abstinence
66.3
65.2
Reduced use
8.4
9.2
Fewer negative consequences
13.3
9.9
Goal set by patient
30.1
26.2
Other goal
3.6
5.7
Source: CASA Columbia Survey of New York State
Addiction Treatment Providers, 2009.
Inadequate Performance and Outcome
Measurement. Government and private funders
and insurance companies increasingly are
pressing addiction treatment programs to
demonstrate the effectiveness of their programs
and services.250 However, most programs do not
measure performance or treatment outcomes or
have reliable evaluation data to demonstrate the
efficacy of their services.251 There is no
national, unified body that sets standards for
addiction treatment.252
CASA Columbia's survey of treatment program
directors in New York State found that, when
asked about the three main ways that their
program evaluates how well it is doing, the most
common response offered was "program
completion rates" (68.7 percent); the next most
common response was "random client
feedback/testimonials" (54.2 percent). Neither
of these measures adequately reflects treatment
quality or effectiveness. Long-term follow up of
patients is not typical, as only 34.9 percent of
program directors reported following patients for
more than six months after treatment exit to
assess how well their patients were faring.253
Further complicating the measurement of
outcomes is the failure to understand that
addiction in many cases is a chronic disease that
requires management over time.
The effectiveness of addiction treatment is
evaluated based on perverted measures of
success... you'd never judge the benefits of an
antihypertensive medication AFTER the
medication had been stopped.15*
-Michael M. Miller, MD
Past President
American Society of Addiction Medicine
Most addiction treatment programs lack
resources to develop and implement effective
measurement systems.255 Integrating addiction
treatment into mainstream health care, however,
would permit the performance and outcome
measures and standards that have been well
established for the treatment of other health
conditions to be applied to addiction treatment
as well.
Inadequate Insurance Coverage
In spite of recent expansions in coverage for
intervention and addiction treatment through
health care parity laws and the Affordable Care
Act, insurance coverage for addiction and
related services remains severely limited
compared with coverage for other health
conditions.* 256 This lack of insurance coverage
for effective— and cost-effective— intervention
and addiction treatment services provides a
further barrier to increasing the attention of
health care professionals to this disease. The
end result is that millions of Americans are
denied treatment, health care costs continue to
rise as do social consequences and costs, and
taxpayers foot the bill.257
See Chapter VIII.
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No Overarching Organizing Body for
Addiction Science and Treatment
Unlike other major health conditions, there is no
highly credible and unifying organization,
within or outside of the National Institutes of
Health (NIH), which sets standards and
advocates for addiction prevention and
treatment, including all manifestations of
addiction.
A key mission of the National Cancer Institute is
to conduct and support "research, training,
health information dissemination and other
programs with respect to the cause, diagnosis,
prevention and treatment of cancer,
rehabilitation from cancer, and the continuing
care of cancer patients and the families of cancer
patients."258 Likewise, according to the
American Heart Association's description of its
organization, "we fund innovative research, fight
for stronger public health policies and provide
lifesaving tools and information to prevent and
treat these diseases."259
Although there are federal institutes and
organizations dedicated to substance use and
addiction, including the National Institute on
Drug Abuse (NIDA), the National Institute on
Alcohol Abuse and Alcoholism (NIAAA) and
the Substance Abuse and Mental Health
Services Administration (SAMHSA) as well as
other organizations and institutes for which
substance use and addiction are part of their
focus,* there is no unified body that promotes
research, public awareness and prevention and
treatment quality for the disease of addiction.
The result is a disjointed array of programs and
efforts that often have quite different
perspectives and approaches to addressing the
issues surrounding substance use and addiction,
which further contributes to the segmented view
of addiction as multiple substance- and
behavior-specific problems, rather than a single
disease with different manifestations.
Such as the National Cancer Institute (NCI),
primarily in relation to smoking, the National
Institute of Mental Health (NIMH) and the Centers
for Disease Control and Prevention (CDC).
A recent plan by the NIH would combine public
health initiatives related to substance use and
all addiction-related research within the NIH
into a new institute focused on substance use
and addiction.260 This proposal is controversial
with regard to how the merger will affect the
funding and research portfolios not only of
NIDA and NIAAA but also of other NIH
institutes with interests that involve substance
use and addiction (e.g., those that address
cancer, HIV, prenatal care, birth defects, obesity,
pain control).261 Its strength is a clear and long-
overdue recognition of the nature of the disease
of addiction and the importance of addressing it
in a unified way.
Efforts to Integrate Substance Use
Prevention and Treatment into
Mainstream Medicine
Recent efforts aimed at improving the
prevention of risky substance use and the
treatment of addiction have concentrated on the
application of quality improvement and quality
assurance measures such as those that have
gained traction in mainstream health care
practice:
• Developing, disseminating and promoting
evidence-based practices;262
• Improving the treatment provider workforce
through enhanced education and training;263
• Improving performance measures;264
• Shifting evaluation efforts from a focus on
performance-based measures that document
the process of service delivery to a focus on
patient outcomes, and rewarding those
programs that demonstrate positive patient
outcomes;265 and
• Using electronic health records and other
forms of health information technology to
track and monitor patients and help improve
the coordination and delivery of care.266
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Many of these efforts, however, have been
aimed at shoring up and maintaining a separate
system of addiction treatment outside of
mainstream health care practice. Although these
are steps in the right direction, the research
documented in this report demonstrates clearly
that the current treatment infrastructure is
riddled with barriers to closing the vast gap
between research evidence and practice.267 As
such, modifications to the existing system
simply will not suffice to make significant,
meaningful and lasting improvements in how
risky substance use and addiction are addressed
in the United States.
What is required is an integration of screening
and intervention for risky substance use and
treatment and management of addiction into
mainstream health care, assuring that addiction
treatment is managed by trained medical
professionals and supported by an array of
highly-trained clinical mental health
professionals and other providers of essential
support and auxiliary services.268 Such
integrated care leads to improved patient
outcomes and significantly-reduced medical
costs.269
Several recent developments have begun to
make significant strides in this direction:
• Efforts to expand insurance coverage for
screening and brief interventions in primary
care settings, to offer equitable coverage for
addiction treatment services and to ensure
accountability by establishing quality
benchmarks in patient care as a condition for
coverage.
270
Efforts by professional societies and
associations to professionalize addiction
treatment, have the medical field respond to
risky substance use as a public health
problem and addiction as a medical
condition, and integrate care for risky
substance use and addiction into medical
practice. Notable examples include:
> The American Society of Addiction
Medicine (ASAM) which is seeking to
improve the quality of care for risky
substance use and addiction by:
educating physicians and other health
professionals about these issues;
supporting research and prevention
efforts; advocating for state and federal
policies that would expand access to
treatment; and working to establish
addiction medicine as a recognized
medical specialty.271
> The American Board of Addiction
Medicine (ABAM), which was founded
in 2007 with the encouragement and
assistance of ASAM, is working toward
the goal of establishing addiction
medicine as a medical specialty
recognized by the American Board of
Medical Specialties (ABMS). ABAM's
sister organization, the ABAM
Foundation, began accrediting one- or
two-year fellowship training programs-
"secondary residencies"— in addiction
medicine open to physicians completing
training in any field certified by the
ABMS member boards. Such
programs have the ability to train the
physician experts needed to meet the
demand within health care teams at all
locations where regular medical care is
received-from hospitals to community
clinics. The ABAM Foundation also is
working toward having its fellowship
training programs accredited by the
Accreditation Counsel for Graduate
Medical Education (ACGME).272
NIAAA and NIDA recently awarded
grants to SUNY Buffalo and to Boston
University Medical Center to help
support this effort.273
> The American Society of Health-
Systems Pharmacists, a member of the
National Pharmacy Partnership for
Tobacco Cessation, which has created a
resource center to provide pharmacists
with tobacco cessation information and
tools to help patients stop smoking.274
The ABAM Foundation to date has accredited 10
addiction medicine training programs across the
country, with more programs under development.
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• Efforts by government agencies to promote
physician education and training in
addiction science and addiction treatment
and upgrade health care professionals' skills
through the development and dissemination
of screening tools and evidence-based
clinical guidelines.275 Notable examples
include:
> The National Institute on Drug Abuse's
NIDAMED, a physician outreach
initiative aimed at encouraging doctors
to screen patients for risky substance
use, including tobacco, alcohol and
other drugs. NIDAMED offers free
screening tools and prevention and
treatment research and information that
physicians can share with their patients.
It also offers curriculum resources to
provide scientifically accurate
information to medical students,
residents and faculty about substance
use, addiction and its consequences.276
> The Substance Abuse and Mental Health
Services Administration's SBIRT*
Medical Residency Program, which
seeks to develop and implement training
programs for medical residents in
evidence-based screening, brief
intervention, brief treatment and referral
to specialty treatment for risky
substance use and addiction involving
alcohol and other drugs, and to promote
more broadly the adoption of these
practices in the medical field.277
> The Health Resources and Services
Administration's Project
MAINSTREAM, which provides
resources for educating a broad range of
health care professionals ' in screening,
brief intervention, referral to treatment,
Screening, Brief Intervention, Referral and
Treatment.
f Including audiologists, dentists, dieticians, nurse
midwives, nurse practitioners, nurses, occupational
therapists, pharmacists, physical therapists, physician
assistants, physicians, psychologists, public health
professionals, social workers and speech pathologists.
identifying and assisting children of
parents with addiction and helping
communities implement effective
prevention programs related to addiction
involving all substances.278
• Smaller-scale efforts to provide brief
training to health professionals1' in addiction
science in order to improve the attitudes,
proficiency and practices of all health
professionals279-not just those who choose
to specialize in addiction medicine or
addiction psychiatry. Such brief trainings
have proven effective in improving health
professionals' knowledge, attitudes,
confidence, motivation and practices with
regard to providing smoking cessation
services;280 conducting screening and brief
interventions for risky alcohol use in
emergency departments281 and for risky
alcohol and other drug use in primary care
facilities;282 and for prescribing
pharmaceutical medications such as
methadone and buprenorphine for patients
with addiction involving opioids.283
• The emergence of Patient-Centered Medical
Homes284-in which a team of health
professionals provides comprehensive and
continuous medical care-is proving to be a
strong model for addiction treatment to be
integrated into the primary medical care
system.285 Recent research within the
Medicaid and Veterans Health
Administration systems demonstrates the
success of this approach286 and the potential
to incorporate addiction care into this
integrated system.
• Efforts by quality assurance organizations to
encourage services that address risky
substance use and addiction within
mainstream health care. For example, in
2012, the Joint Commission announced new,
voluntary measures for hospitals that choose
to provide screening, brief intervention and
referral to treatment for tobacco, alcohol and
1 Including but not limited to physicians, physician
assistants, nurses, nurse practitioners, dental
professionals, pharmacists, social workers.
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other drug use. The performance
measurement sets related to alcohol and
other drugs include screening, brief
interventions, treatment, discharge planning
and follow up.287 The specifications for the
tobacco cessation performance measures
include screening all patients to identify
tobacco users, providing or offering
evidence-based counseling and medications
for smokers during hospitalization and upon
discharge, and assessing tobacco use 30
days post-discharge.288 Hospitals are
required to choose four out of 14 possible
core performance measurement sets, with no
requirements about which sets must be
chosen.289 For each core performance
measurement set that the hospital chooses,
the hospital is held accountable for
collecting data and measuring performance
related to the activities associated with the
set. However, other sets of measures that
hospitals may choose to be held accountable
for include those that they already perform
routinely, limiting the reach of this
promising development which would require
more effort and resources than most other
290
measurement sets.
Our perspective is that, although tactically
impressive, the [Joint Commission's]
measure set [regarding tobacco screening and
cessation services] is strategically flawed
because its adoption is optional.291
-Fiore, M.C., Goplerud, E., &
Schroeder, S. A. (2012)
If the Joint Commission would require
hospitals to report their outcomes on SBIRT,
it could do more to medicalize how we deal
with risky substance use than all the urging
and pleading we 've undertaken for the past
25 to 30 years.292
-Larry M. Gentilello, MD
Trauma Services
Kaiser Permanente Hospital
Sacramento, CA
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Chapter XI
Recommendations and Next Steps
As this report has documented, addiction is a
complex brain disease and the risky use of
addictive substances is a significant public
health problem. Together they result in untold
human suffering and cost taxpayers billions of
dollars each year. Effective, evidence-based
interventions and treatment options exist that
can and should be delivered through the health
care system. A substantial body of research
demonstrates that providing effective
prevention, intervention, treatment and disease
management services yields improvements in
health and considerable reductions in costs to
government and taxpayers; research also
suggests that providing these services does not
result in significant increases in insurance costs.
In the face of these facts, it is unethical,
inhumane and cost prohibitive to continue to
deny effective care and treatment for the 40.3
million Americans with this disease or to fail to
screen and intervene with the 80.4 million who
engage in risky use of addictive substances.
No one group or sector alone can realize the
changes required in health care practice,
government regulation and spending, insurance
coverage, and public understanding to bring
addiction prevention and treatment and
reductions in risky substance use in line with the
standard of care for other public health and
medical conditions. Concerted action is required
on the part of physicians and other medical and
health professionals, policy makers, insurers and
the general public.
This is not an unprecedented challenge. There
have been many examples where health care
practice has lagged behind the science. Only
recently, depression was considered a character
flaw before the brain science was understood
and HIV/AIDS was considered a moral scourge
before it was seen as a virus that can be
prevented, treated, managed and perhaps cured.
Likewise, addiction has been seen for too long
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as a character flaw and a moral failing rather
than a preventable and treatable disease.
It is past time for health care practice to catch up
with the science. Efforts already underway to
close this gap must be expanded and accelerated.
Toward this end, CASA Columbia makes the
following recommendations:
Reform Health Care Practice
Incorporate Screening and Intervention for
Risky Substance Use, and Diagnosis,
Treatment and Disease Management for
Addiction into Routine Medical Practice
As essential components of routine medical care
practice, all physicians and other medical
professionals should provide their patients with:
• Routine screening for all forms
of risky substance use—including tobacco,
alcohol, illicit drugs and controlled
prescription drugs-at initial visit to a
primary care or specialty care physician and
routinely thereafter, and upon entry into a
hospital, emergency department, trauma
center or clinic;
• Brief interventions as needed;
• Comprehensive assessment to determine
disease stage and severity as well as the
presence of co-occurring health conditions
and special population needs;
• Patient stabilization (e.g., detoxification),
when necessary, as a precursor to treatment;
• Development of a tailored treatment plan
that includes:
> Acute treatment via evidence-based
psychosocial and/or pharmaceutical
interventions;
> Chronic disease management, as
needed;
> Connection to support and auxiliary
services-including legal, educational,
employment, housing and family
supports, nutrition and exercise
counseling, and mutual support
programs; and
> Referral to physicians trained in
addiction medicine or addiction
psychiatry for specialty care as needed.
Evidence-based screening can be conducted by a
broad-range of licensed providers with general
training in addiction and specific training in how
to conduct such screens and what to do with
patients who screen positive. Brief interventions
can be provided by health professionals-
licensed graduate-level medical or mental health
clinicians-trained in addiction care.
Treatment and disease management services can
be provided through a multi-disciplinary team of
appropriately trained and credentialed health
professionals managed by a physician:
• Comprehensive assessment, diagnosis,
stabilization, acute treatment and disease
management must be performed or managed
by physicians in collaboration with a team
of licensed graduate- level medical or mental
health clinicians trained in addiction care;
• Case management can be provided by
licensed physician assistants, nurses and
nurse practitioners and mental health
clinicians trained in addiction care;
• Auxiliary services can be provided by a
range of professional and paraprofessional
personnel working within the treatment and
disease management plan;
• Peer support, often an important component
of the larger treatment plan, can be provided
by those who have learned to manage the
disease.
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All Medical Schools and Residency
Training Programs Should Educate and
Train Physicians to Address Risky
Substance Use and Addiction
All physicians should be educated and trained in
the origins of risky substance use and addiction;
prevention, intervention, treatment and
management options; co-occurring conditions;
and special population and specialty-care needs,
including:
• What constitutes risky substance use, the
harms of such use to health and safety and
the importance of reducing risky use;
• How to screen for risky substance use and
conduct brief interventions when indicated;
• The causes and correlates of addiction;
• How to diagnose addiction; evaluate disease
stage, severity, co-occurring disorders and
needs of special populations; and develop a
treatment and disease management plan
including appropriate support services;
• How to collaborate with and manage a
multidisciplinary team of providers;
• How to provide or supervise psychosocial
and pharmaceutical treatments for addiction
and disease management;
• How to arrange for and connect patients
with auxiliary support services; and
• How to determine the need for specialty care
and connect patients with such care.
These core clinical competencies should be
required components of all medical school
curricula, medical residency training programs,
medical licensing exams, board certification
exams and continuing medical education (CME)
requirements, including maintenance of
certification programs.
Require Non-Physician Health
Professionals to be Educated and Trained
to Address Risky Substance Use and
Addiction
Develop core clinical competencies in
addressing risky substance use and preventing
and treating addiction for each type of non-
physician health professional including
physician assistants, nurses and nurse
practitioners, dentists, pharmacists and graduate-
level clinical mental health professionals
(psychologists, social workers, counselors).
These competencies should include:
• What constitutes risky substance use, the
harms of such use to health and safety and
the importance of reducing risky use;
• How to screen for risky substance use and
conduct brief interventions when indicated;
• The causes and correlates of addiction;
• Available psychosocial and pharmaceutical
treatments for addiction and disease
management;
• How to arrange for and connect patients
with auxiliary support services; and
• How to determine the need for specialty care
and connect patients with such care.
Assure that these core clinical competencies and
specialized training are required components of
all professional health care program curricula,
graduate fellowship training programs,
professional licensing exams and continuing
education (CE) requirements.
For non-physician health professionals involved
in the provision of addiction care, core
competencies also should include how to work
in concert with a patient's physician and other
health care providers to screen for risky
substance use; provide brief interventions;
diagnose addiction; evaluate disease stage,
severity and co-occurring disorders; and develop
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a treatment plan, including appropriate support
services.
Require all non-physician health professionals
providing psychosocial addiction treatment
services to have graduate-level clinical training
in delivering these services.
Require that all pharmaceutical treatments for
addiction be provided only by a physician or in
accordance with a treatment plan managed by a
physician.
Develop Improved Screening and
Assessment Instruments
Screening instruments should be adjusted or
developed to coincide with appropriate
definitions of risky substance use, and
assessment instruments should be adjusted or
developed to mirror diagnostic criteria for
addiction. Both screening and assessment
instruments should address all types of addictive
substances.
Establish National Accreditation Standards
for All Addiction Treatment Facilities and
Programs that Reflect Evidence-Based
Care
As a condition of accreditation, accrediting
organizations should stipulate requirements for
all facilities and programs providing addiction
treatment with regard to professional staffing,
intervention and treatment services and quality
assurance:
• Professional Staffing. All facilities and
programs providing addiction treatment
should be required to have a full-time
certified addiction physician specialist on
staff to serve as medical director, oversee
patient care and be responsible for all
treatment services. All individual providers
of patient care in these facilities and
programs should be required to be licensed
in their field of practice and demonstrate
mastery of the core clinical competencies.
Professionals who are in the process of
becoming licensed must be supervised at all
tim